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Health Personnel in the United States 



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Health Resources and Services Administration 

"HRSA— Helping Build A Healthier Nation" 

The Health Resources and Services 
Administration has leadership responsibility in 
the U.S. Public Health Service for health service 
and resource issues. HRSA pursues its 
objectives by: 

■ Supporting states and communities in 
delivering health care to underserved 
residents, mothers and children and other 
groups; 

■ Participating in the campaign against 
AIDS; 

■ Serving as a focal point for federal organ 
transplant activities; 

■ Providing leadership in improving health 
professions training; 

■ Tracking the supply of health professionals 
and monitoring their competence through 
operation of a nationwide data bank on 
malpractice claims and sanctions; and 

■ Monitoring developments affecting health 
facilities, especially those in rural areas. 



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1993 



Office of Minority Health 
Resource Center 

ia/ u FOBox 37337 
Washington, DC 20013-733? 



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Health Personnel in the United States 




DHHS Publication No. P-OD-94-1 



ii • Health Personnel in the United States • Ninth Report to Congress • 1993 



Introduction 



Legislation enacted in the 1970s requires the periodic 
submission of reports by the Secretary of the Department 
of Health and Human Services (DHHS) to the Congress on 
the status of health personnel supply, distribution, and 
requirements needed to provide adequate health care for 
the Nation. The current legislative basis for these reports 
is Section 792(d) of the Public Health Service Act as 
renumbered by P.L. 102-408, the Health Professions 
Education Extension Amendments of 1992. Section 792(d) 
was formerly Section 708(d) of the Public Health Service 
Act, as amended by P.L. 94-484 and further amended by 
P.L. 95-623, P.L. 100-607 and P.L. 100-690. In addition, 
separate legislation mandates reports to Congress on 
nursing supply, distribution, and requirements (Section 
951 of P.L. 94-63 as amended by P.L. 95-623), and on public 
health personnel (Section 794(c) of the Public Health 
Service Act as amended by P.L. 94-484 and P.L. 95-623 and 
renumbered Section 793(c) of the Act by P.L. 102-408). This 
ninth report, required by the above noted legislation, 
presents information on issues affecting health personnel, 
and data on the health professions of medicine, dentistry, 
nursing, physician assistants, allied health, public health, 
pharmacy, optometry, podiatric medicine, chiropractic, 
clinical psychology, clinical social work, and veterinary 
medicine. 

This current Report represents an attempt to more 
accurately depict the status of health care personnel in the 
United States. Much of the data on health care personnel 
in the United States that appeared in previous reports can 
now be found in a sister publication entitled Factbook: 
Health Personnel, United States. This report draws on data 
from the Factbook and other information to identify and 
discuss some of the universally important health care 
issues that are expected to affect the delivery of health care 
and the demand for health care personnel. 



The health care system of our Nation is being 
fundementally altered as society struggles to reduce costs 
while maintaining quality and in some areas expanding 
care. Undoubtedly, any change in how health care is 
delivered to the residents of this country will also have an 
effect on the personnel who deliver this care. This report 
presents primary issues affecting the health professions. 
The changing health care system, the major issue facing 
health personnel, is discussed along with other important 
and emerging issues such as the declining interest in 
primary care careers, barriers to practice for nurse 
practitioners, certified nurse midwives, and physician 
assistants, minority representation and minority health 
concerns, rural health personnel, nurse workforce issues, 
and the varying health care needs of persons with AIDS. 
Financing and reimbursement issues have and continue to 
be examined and analyzed by the Health Care Financing 
Administration, Prospective Payment Assessment 
Commission and the Physician Payment Review 
Commission along with others. Therefore, despite the 
importance of these topics to the health workforce, they 
are not covered in this report. 

This ninth report also discusses occupation-specific 
issues that are affecting or could affect an occupation's 
contribution to the delivery of health care to the 
population. The report provides information on 
physicians, physician assistants, dentists, nurses, allied 
health occupations, optometrists, pharmacists, podiatrists, 
chiropractors, clinical psychologists, clinical social 
workers, public health, and veterinary medicine. 



2993 • Health Personnel in the United States • Ninth Report to Congress • 1 






2 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Table of Contents 



Introduction 1 

Table of Contents 3 

Executive Summary 5 

Major Issues 

State-level Health Care Reform Initiaitves, Potential 
Implications for the Health Workforce 13 

Primary Care Concerns 17 

Analysis of Barriers to Expansion of Clinical 
Practice for Nurse Practitioners and Certified 
Nurse-Midwives 21 

Barriers to Physician Assistant Practice 27 

Status of Minority and Women Health Care 

Personnel: Availability to Provide Care to 

Special Populations 33 

Health Care in Rural America 37 

Preparing a Nurse Workforce Appropriate for 

Current and Future Health Care Delivery 43 

Health Care Services for Persons 

with HIV/AIDS 47 



Individual Disciplines 

Physicians 53 

Physician Assistants 59 

Dentists 63 

Nurses 67 

Allied Health Introduction 73 

Dental Hygienists 75 

Physical Therapists 77 

Occupational Therapists 79 

Speech-Language Pathologists 

and Audiologists 81 

Respiratory Therapy Personnel 83 

Dietitians 85 

Diagnostic Imaging and Ionizing 

Therapy Personnel 87 

Medical Records Personnel 89 

Clinical Laboratory Personnel 91 

Public Health 93 

Pharmacists 95 

Optometrists 97 

Podiatrists : 99 

Chiropractors 101 

Clinical Psychologists 103 

Clinical Social Workers 105 

Veterinarians 107 

List of Figures and Tables 108 



1993 • Health Personnel in the United States • Ninth Report to Congress • 3 






4 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Executive Summary 



Health Personnel in the United States: Ninth Report to 
Congress, 1993, is submitted by the Secretary of the 
Department of Health and Human Services (DHHS) in 
response to directives of several legislative authorities. 
This report provides an overview of primary issues 
affecting the health professions, in particular the evolving 
health care financing and delivery system. Other 
important and emerging issues presented include the 
declining interest in primary care careers; restrictive State 
practice laws or acts that currently prevent nurse 
practitioners, certified nurse midwives, and physician 
assistants from using their full range of skills and 
capabilities; the underrepresentation of minorities in 
health professions and its impact on minority health; 
causes of shortages of health personnel in rural areas and 
associated problems of affordability and access to health 
care; the need for an appropriately trained nursing 
workforce; and the varying health care needs of persons 
with HIV/AIDS. Also discussed by profession, are issues 
which affect the supply, distribution, and adequacy of each 
discipline's ability to provide health care. Information and 
data are presented on physicians, physician assistants, 
dentists, nurses, allied health occupations, public health 
personnel, pharmacists, optometrists, podiatrists, 
chiropractors, clinical psychologists, clinical social 
workers, and veterinarians. 

This report's format is different than that of earlier 
editions. The report represents an attempt to depict the 
status of health care personnel in the United States by 
identifying the issues affecting them. Much of the data on 
health care personnel that appeared in previous reports 
can be found in a companion publication entitled Factbook: 
Health Personnel, United States. This report draws on data 
from the Factbook and other sources to identify and discuss 
important health care issues that will affect the delivery of 
health care and the demand for health care personnel. 



Major Issues 

State-level Health Care Reform Initiatives 

The ongoing changes in the financing and delivery of 
health care, especially at the State level, has been the 
product of efforts to provide more comprehensive 
coverage and reduce the rate that costs are growing. 
Undoubtedly, any change that alters the delivery of health 
care also will affect the personnel needed to deliver this 
care. 

Several elements of the changing health care system 
will have a direct impact on requirements for health 
personnel and require changes in the mix and type of 
training they receive. Among these issues are the growth 
of managed care systems which rely heavily on 
gatekeepers to ensure appropriate care, and increased 
emphasis on preventive and primary care services in order 
to control the long-term costs resulting from inadequate 
access to care. 

Primary Care Concerns 

Most agree that access to primary care is beneficial to 
the overall health of the population and helps to control 
costs. For this reason, expanding primary and preventive 
services has been a major objective of those seeking to 
improve the existing health care system. Primary health 
care includes a comprehensive range of public health, 
preventive, diagnostic, therapeutic, and rehabilitative 
services, the goals of which are to prevent premature 
death, disease and disability; preserve functional capacity; 
and enhance overall quality of life. A wide variety of 
health care professionals either provide primary medical 
care or contribute to its provision. These include 
generalist physicians; some physician assistants and 
nurses, most notably nurse practitioners and certified 
nurse midwives; dentists; podiatrists; and to a lesser 
degree pharmacists and a few allied health professionals. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 5 



The domination of our system by specialized health 
care providers and the dearth of adequately trained 
primary care personnel have inhibited access to care and 
helped escalate health care costs. Any movement toward a 
more managed care approach to providing health care will 
exacerbate the imbalance between the need for generalists 
and the demand for these health care professionals as 
demand for primary care personnel increases. To meet 
future workforce needs, teaching hospitals, ambulatory 
facilities, health professions schools, public agencies, and 
other private entities must assure that an appropriate 
number and mix of health professionals are trained in an 
environment conducive to preparing professionals to 
deliver primary care that is cost-effective, person-oriented, 
interdisciplinary, and community-based. 

Barriers to Practice for Nurse Practitioners, 
Certified Nurse-Midwives and Physician 
Assistants 

Concern over the lack of primary care practitioners, 
coupled with ongoing efforts to increase access to care for 
the uninsured and improve preventive services for all, has 
brought focus on the use of nurse practitioners (NPs), 
certified nurse-midwives (CNMs), and physician assistants 
(PAs) as a means of providing primary care. Currently, the 
extent to which these health care professionals can provide 
primary care is governed by a variety of restrictive State 
regulations and reimbursement policies. The barriers to 
practice affecting each profession are similar in many ways 
but with some differences that affect their practice 
environment. The net result, however, is that the optimal 
use of these practitioners is being compromised. States 
regulate their respective scopes of practice and in many 
jurisdictions, despite adequate educational preparation, 
NPs, CNMs and PAs are unable to perform the services for 
which they were trained. The full utilization of the skills 
of these practitioners would have a major positive effect on 
achieving the goals of improving health care delivery. 



Status of Minority and Women Health Care 
Personnel: Availability to Provide Care to 
Special Populations. 

While women have historically dominated the majority 
of nursing and allied health professions, the 1980s and 
1990s also saw them contribute significantly to the growth 
in traditionally male-dominated occupations such as 
medicine, dentistry, and optometry. The growth rate of 
minority women in health care occupations has also been 
substantial, although such women continue to represent a 
very small percentage of health professions graduates as a 
whole. Black women, for instance, were solely responsible 
for increased black representation in medicine and 
dentistry. The loss of black male professionals in some 
fields and their failure to match the gains of black women 
in others, represents a critical setback that needs to be 
addressed. Similarly, while the growth of Hispanic 
women in allopathic and osteopathic medicine, dentistry, 
pharmacy, optometry, podiatry, and veterinary medicine 
has exceeded that of all women, their still very small 
numbers limit their availability to treat the populations 
that need them most. This is of special concern in that 
Hispanics are the fastest growing minority population in 
the United States. 

Many of the national health goals for the year 2000 that 
target women and children in low-income and minority 
groups depend on increasing the supply of women and 
other minority health care providers to bridge the 
language and cultural gap that often inhibits access to care. 
While women will continue to increase their 
representation in many of the health care professions, an 
inadequate supply will serve as a constraint on the 
Nation's efforts to treat the populations that need them 
most. The declining numbers of black male graduates in 
some professions and the continued underrepresentation 
of other minorities indicate renewed efforts are needed to 
increase the recruitment and retention of these 
populations. 



6 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Health Care in Rural America 

Affordable and accessible quality health care delivery 
has always been difficult to find in rural areas. If the 
ongoing changes in health care are to improve access to 
care for rural populations, they must address the issues 
specific to rural populations such as inadequate numbers 
of providers; failing rural hospitals; high incidence of 
agricultural and occupational health problems; lack of 
mental health and rehabilitative services; and deteriorating 
emergency medical systems. To adequately address the 
needs of rural populations, policymakers will need to 
identify and examine differences in urban and rural 
practice and to make appropriate accommodations to 
correct these differences. 

Preparing a Nurse Workforce Appropriate for 
Current and Future Health Care Delivery 

The key to preparing an adequately trained nurse 
workforce capable of handling the added responsibilities 
that may result from an evolving health care delivery 
system is nursing education. Nursing and nursing 
education are being challenged to provide for the increases 
in demand for baccalaureate-prepared professional nurses 
and master's- prepared advanced practice nurses in 
nonhospital settings. 

Entry into nursing primarily continues along three 
pathways: hospital diploma programs, 2-year associate 
degree programs, and 4-year baccalaureate programs. The 
percent of graduates earning baccalaureate degrees has 
remained about the same, while the percent of associate 
degrees has risen to represent about two-thirds of all new 
graduates. The irony of this trend is that future demand 
for nurses will be oriented toward the baccalaureate- 
prepared nurse. Community nursing and the increasing 
trend toward ambulatory care will require broad based 
education most commonly found in baccalaureate 
programs. Furthermore, the bachelor's degree is required 
for entrance into advanced nursing training. 



At the master's level, highly skilled advanced practice 
nurses are being promoted as primary health care 
providers useful in providing care in settings such as 
ambulatory primary care clinics. The task is to increase 
the number of advanced practice nurses in all specialties to 
aid in expanding access to care in a cost-effective manner. 

Health Care Services for Persons with 
HIV/AIDS 

The human immunodeficiency virus (HIV) epidemic 
continues to have an impact on every segment of our 
health care system. The Centers for Disease Control and 
Prevention (CDC) estimates that over one million persons 
are infected with HIV in the United States. Furthermore, 
about 40,000 persons are likely to become infected 
annually in the United States in the 1990s. Beyond treating 
persons with AIDS, additional resources have been 
dedicated to health education, testing, monitoring, and 
HIV prophylaxis. Still, more services are needed than are 
being provided. A recent study estimated that as few as 
one-third of those infected receive health services specific 
to their infections on a regular basis. Even among those 
symptomatic of HIV, only half received non-home health 
services in 1991. 

At the same time, tuberculosis (TB) has again become a 
national public health concern. CDC estimates there are 
100,000 persons co-infected with HIV and TB in the United 
States. Furthermore, new multi-drug resistant strains of 
TB have increased the need for preventive and therapeutic 
services for HIV and vulnerable populations. Efforts to 
combat the spread of either infection must include special 
preparation of health personnel to provide health 
services— especially in hospitals, substance abuse 
programs, prisons, and programs for the homeless. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 7 



Discussion of Disciplines 

Physicians 

In 1992, there were approximately 597,400 active 
allopathic physicians in the United States, 74 percent of 
whom provided patient care. In addition, there were 
approximately 32,500 osteopathic physicians in 1993. 
Despite an apparently adequate if not excessive supply of 
physicians, physician supply is expected to continue 
increasing at a rate faster than the growth in the 
population. Initially, expansion of the physician supply 
was viewed positively as a way of increasing minority 
representation and improving access to underserved 
populations. The steady expansion, however, has not had 
these desired effects. Most physicians continue to locate in 
highly populated areas where the consequence may be 
over-doctoring leading to unnecessary increases in health 
care expenditures. 

Despite rapid overall growth, only 33 percent of 
allopathic physicians providing patient care specialized in 
the important primary care fields of general and family 
medicine, general internal medicine, and general 
pediatrics. As of 1992, only 15 percent of medical school 
graduates were interested in pursuing primary care 
training. In contrast, 46 percent of active osteopathic 
physicians were primary care physicians. Because primary 
care physicians are more prevention minded and more 
likely to work in underserved areas, it is expected that 
demand for them will increase in conjunction with the 
expected expansion of managed care systems, which rely 
heavily on primary care physicians. 

Concerns about an oversupply of physicians coupled 
with an inadequate supply of primary care specialists have 
caused the Council on Graduate Medical Education to 
recommend, in part, that the supply of physicians be 
limited through a capping of residency positions to 110 
percent of total graduates from U.S. medical schools, and 
that the Nation should move toward a system where 50 
percent of the physician population practices in a primary 
care specialty. 



Physician Assistants 

Physician assistants (PAs) are recognized by law in 47 
States and the District of Columbia as skilled health care 
providers authorized to diagnose illness, order and 
interpret lab tests, establish treatment plans, conduct 
physical exams, and provide general health care services 
under the direct supervision of a physician. 

As of June 1993, there were about 23,300 practicing PAs. 
Because PAs are more likely than physicians to specialize 
in a primary care field, and are more likely to work in 
underserved areas, PAs are being promoted as one of the 
ways of increasing the number of primary care providers 
in underserved areas. The expectation that PAs will play 
an expanded role in the evolving health care system has 
resulted in several proposals to increase their numbers. 
One proposal calls for an attempt to double the annual 
number of PA graduates to nearly 3,500 by 2000 and to 
double the supply by 2005. 

Dentists 

The American Dental Association estimated that there 
were 155,000 active dentists in 1992. Indications are that 
the supply is adequate to meet current economic demand. 
Despite improvements in the Nation's overall oral health, 
a significant share of the population continues to suffer 
from untreated problems because oral health tends to be 
financially inaccessible and unavailable in some rural and 
low-income areas. Greater than 40 percent of the 
population fails to receive any dental care in any 12-month 
period, an unfortunate fact since most dental problems are 
easily prevented, but are not self-limiting. 



8 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Nurses 

Nursing constitutes the largest segment of those 
employed in health care with 1.8 million employed RNs in 
1992; 550,000 employed LPN/VNs in 1991; and about 1 to 
1.1 million employed as assistive nursing personnel. The 
demand for nurses is projected to increase considerably 
due in part to expansion of care in nontraditional settings, 
improved technologies, the aging of the population, and 
the emphasis on health promotion and disease prevention. 
Estimates of future demand for nurses will need to account 
for nursing's changing role in the evolving health care 
system, and the role nurse practitioners and nurse 
midwives can play in providing cost-effective care. 

The two previous reports identified an insufficient 
supply of RNs to fill existing demand. Recent indicators 
suggest that, for the present, the shortage has eased. 
Factors possibly contributing to the easing of the shortage 
include an increase in the number of basic nursing 
graduates after decreases during the mid-eighties, and a 
greater tendency for licensed RNs to be employed. 

Future needs must be viewed from a variety of 
perspectives. While current enrollments are increasing, it 
must be remembered that there are many factors affecting 
choices individuals might make about becoming an RN. 
In addition, demographics of the workforce must be taken 
into consideration; new graduates are coming from older 
segments of the population and the average age of the 
registered nurse population continues to rise. So, while 
increasing enrollments and greater participation of 
licensed RNs in the labor force paints a more optimistic 
picture than what was reported in the Eighth Report to 
Congress, the aging of the population and increasing 
demand for RNs remain a concern. 



Allied Health 

Employment in allied health occupations grew 42 
percent between 1983 and 1992, from 1.5 to 2.1 million, 
about two-and-one-half times the rate for all occupations 
as a whole over the same time period. More significant is 
that employment in these occupations is projected to grow 
50 percent between 1990 and 2005, a rate significantly 
higher than the 29 percent growth projected for physicians 
and higher than the 44 percent growth projected for the 
nursing occupations. Indications of shortages are already 
being reported. AHA data show that the professions with 
the five highest full-time hospital vacancy rates in 1991 
were physical therapists, occupational therapists, radiation 
therapy technologists, cytotechnologists, and speech 
pathologists. 

Rapid projected growth for the allied health professions 
is based largely on the expectation that while new 
technologies and new equipment will protect and preserve 
life, they will also result in greater demand for long-term 
rehabilitative services. New technologies will also increase 
the need for personnel to operate diagnostic equipment 
and to perform diagnostic laboratory tests. Finally, 
population growth, especially in the rapidly growing 
elderly segment, will increase the demand for chronic care 
services such as those provided by occupational and 
physical therapists. 

Public Health 

Although often viewed as a provider of last resort, 
public health's primary goal is not the provision of 
individual care but of promoting health and prevention of 
community-wide diseases. These latter goals should be 
accomplished through public health's three core functions 
of 1) assessing community health and its needs, 2) 
promoting public health's skills and knowledge as a tool to 
developing sound public health policy, and 3) assuring 
that mandated services are provided. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 9 



Fulfillment of these goals requires the work of a 
variety of public health professionals, including 
physicians, nurses, dentists, epidemiologists, 
environmental health personnel, industrial hygienists, 
health service administrators, nutritionists, social workers, 
and educators. 

The promise of increased reliance on managed care in 
the evolving health care delivery system could increase the 
demand for public health professionals. Increased reliance 
on managed care for instance, could result in HMOs hiring 
epidemiologists to evaluate disease prevalence and devise 
prevention strategies. 

On the other hand, the changing health care financing 
and delivery system could also create new problems for 
public health departments. Because public health is 
generally perceived as a provider of health care, interest in 
supporting public health agencies may decline if health 
insurance coverage increases and health maintenance 
organizations become more accountable for the health of 
the population. At risk are public health's other important 
functions of identifying community-wide disease 
prevalence, development of health promotion activities, 
and protection of public water and food supplies. 

This section also discusses the ongoing issue of how to 
provide an adequate and appropriately trained supply of 
public health professionals to respond to evolving public 
health needs. 



Pharmacists 

There were about 172,000 active pharmacists in 1992. 
After several years of declining enrollments and other 
factors consistent with a shortage, the numbers of 
applicants, enrollments, and programs are again on the 
increase. The profession is currently facing several issues: 
One is a proposal to increase the basic entry-level 
educational requirement to a 6-year program; another is 
pharmacy's need to become more consumer rather than 
product oriented, and the effect this trend will have on 
pharmacists. Medicaid regulations requiring patient 
counseling and drug use review have raised concerns 
about appropriate compensation for services that require a 
pharmacist's time but may not result in the dispensing of a 
product. 

Optometrists 

According to the American Optometric Association, 
there were approximately 27,600 full-time equivalent 
optometrists in 1993. Currently, the supply of optometrists 
appears adequate and is projected to grow at a rate faster 
than that of the population. 

Optometry continues to increase its market as States 
expand the practice acts governing the profession. From 
performing simple eye exams for purposes of prescribing 
lenses in the early 1970s, optometric practice has expanded 
to include the use of diagnostic drugs in all States, and 
therapeutic drugs to treat certain eye diseases in many 
States. In addition, Medicare now defines optometrists as 
"physicians," allowing them to apply for reimbursement 
for services provided to those over 65. A number of 
studies have shown that optometrists tend to charge less 
than ophthalmologists. If these studies are accurate, then 
changes in Medicare and State scope-of-practice laws 
could reduce costs and improve access by transferring 
demand from more expensive ophthalmologists to less 
expensive and more plentiful optometrists. 



10 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Podiatrists 

The American Podiatric Medical Association estimated 
that there were about 13,000 practicing podiatrists in 1993. 
Although podiatrists are defined as "physicians" by all 
third-party payers for purposes of reimbursement, there is 
concern about the possible effects of the evolving health 
care delivery system on this occupation which consists 
primarily of private practitioners (roughly 70 percent). 
Should the changing health care system emphasize a 
managed care approach, podiatrists will need to develop 
affiliations with managed care organizations. 

Another issue is the uneven distribution of podiatrists 
throughout the United States. Nearly 50 percent of all 
podiatrists are located in the seven States having podiatry 
training programs. Because podiatrists would appear to be 
less expensive than either primary care physicians or 
orthopedists who can provide the same services, a 
redistribution could be advantageous. There are 
questions, however, about how this can be accomplished. 

Chiropractors 

As of 1990, there were between 45,000 and 50,000 
licensed chiropractors in the United States. As with 
podiatrists, chiropractors have a high rate of self- 
employment and should a managed care system become 
the norm, chiropractors would need to form affiliations 
with HMOs and PPOs. Because these systems have 
displayed a hesitancy in employing chiropractors, those in 
the profession run the risk of being excluded from a large 
share of the market. 

Chiropractic also believes Medicare reimbursement is 
inadequate. Although defined as a "physician" for 
purposes of reimbursement, Medicare pays chiropractors 
only for manipulation of the spine. Services such as X-rays 
or other clinical services are not covered by Medicare and 
must be paid out of pocket or with secondary insurance. 
Chiropractors view this as an impediment to individuals 
who would prefer to receive care from a chiropractor, but 
choose an allopathic or osteopathic physician because their 
services are more likely to be covered. 



Clinical Psychologists and Clinical Social 
Workers 

Reliable supply estimates of clinical psychologists and 
clinical social workers do not exist, and the task of 
estimating demand for them is difficult because a number 
of other occupations are capable of substituting for them. 

As with other health care professions, the evolving 
health care system is the major issue facing these 
occupations. 

Changes in the financing and delivery of health care 
could significantly change the utilization patterns of 
mental health care providers, and result in more intensive 
short-term services that could ultimately result in the need 
to alter training programs. 

Other concerns facing these occupations include 
questions about the cost-effectiveness of extending 
reimbursement to specialists not currently covered; ways 
of being more consumer oriented and adaptable to meet 
both the physical and mental needs of clients; and the need 
to foster greater collaboration among the growing body of 
mental health professionals. 

These and additional issues are discussed in the 
publication Mental Health, United States, 1992 which is 
produced jointly by the National Institute of Mental 
Health and the Substance Abuse and Mental Health 
Services Administration. 

Veterinarians 

There were about 47,000 veterinarians employed in 
1990. Rapid growth in pet ownership is expected to drive 
demand for veterinarians up to about 62,000 by 2005. 

Issues facing veterinarians include a growing role in 
helping to determine what constitutes the ethical treatment 
of animals in medical research and product testing, and 
how veterinary medicine can help address the changing 
nature of high technology farming with its associated 
problems of disease and use of chemicals and hormones. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 11 



12 • Health Personnel in the United States • Ninth Report to Congress • 1993 



State-Level Health Care Reform Initiatives, 
Potential Implications for the Health Workforce 



Background and Introduction 

Medical care in the United States extracts enormous 
individual and societal costs, and these costs continue to 
escalate. As the Gross Domestic Product (GDP) proportion 
of health care expenditures has risen in recent decades, 
relative resources available for education, social programs, 
and other public needs have been drained. The health care 
industry in 1993 accounted for nearly $1 trillion, or one 
seventh, of the nation's public and private economic 
output (GDP). At the same time, 37 million Americans 
have no health care coverage; and although most of these 
are young, working individuals who are without coverage 
for only part of the year, they often get care later than they 
should and in high cost settings such as the nation's 
overburdened emergency rooms. 1 Millions more have 
coverage which is subject to cancellation or subject to 
substantial premium increases at a time when their 
insurance needs are highest. Furthermore, many 
individuals living in the inner cities and rural areas lack 
access to providers due to cultural, geographic, and 
financial barriers to care. Partly as a result of this 
inadequate access to health care, the United States ranks 
poorly on many measures of health status. In a 1990 
comparison with 23 other developed countries, the United 
States ranked in the bottom half in universal health status 
indicators such as infant mortality and male or female life 
expectancy, despite the fact that we spend more than twice 
as much per capita on health care than the 24-nation 
average. 2 

While offering remarkably sophisticated treatment of 
diseases, and an array of medical services and procedures 
to the wealthy and well-insured (with sometimes 
questionable necessity and outcomes), the nation's health 
care delivery system is unable to provide simple, basic care 
to large segments of the population. 



Herbert G. Traxler 1 * 



The continued rapid escalation of already enormous 
health care costs, coupled with disappointing health 
outcomes and worsening access for some population 
groups, have led many States, hospitals, insurers, and 
providers to work together in an effort to reduce costs 
while maintaining quality care, and in some cases to 
expand coverage. The governors and legislatures of many 
States have been preparing legislative proposals to change 
the way health care is organized, financed, and delivered, 
with the goal of containing escalating health care costs 
while improving access and quality of health care. 

Health Care System Reforms 

Despite the lack of a consensus at the national level, 
many States have forged their own reform programs. 
While the final shape of the changing health care system 
has yet to be determined, the States' intended purpose of 
expanding coverage will certainly alter the demand for 
health care providers. Concern over how State-level 
health care changes will affect demand for labor has 
increased. It is now conceded that changes will ultimately 
affect not only the requirements but the supply and 
training of those who provide care: physicians and 
physician assistants, nurse practitioners, certified nurse- 
midwives, registered and licensed practical nurses, allied 
health professionals, public health professionals and 
mental health providers. 

Physician payment reform is essential to address 
inequities in payments across clinical specialties, which 
currently value procedural activities over cognitive 
services. Medicare's introduction of the Resource Based 
Relative Value Scale (RBRVS) increases the payment for 
assessment and management services relative to 
procedural services. It is an initial step to stimulate shifts 
in physician activities toward less invasive and more 
cognitive services, albeit it applies only to the elderly at 
this time. Additional changes required in the health 
workforce are discernible. Many of these are contained in 



1 * The author gratefully acknowledges the substantive and editorial 
contributions by Dr. Carol Bazell, Ms. Sandy Gamliel, and Ms. Stephanie 
Sansom. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 13 



the findings and recommendations of the Council on 
Graduate Medical Education's (COGME) recent third 
report, entitled Improving Access to Health Care Through 
Physician Workforce Reform: Directions for the 21st Century, 
one of the key documents in this area, focusing on 
physicians. 3 

Requirements 

Improving financial access to health care for 
underserved populations in States will have an enormous 
impact on the health professions. Expanded access for 
individuals will increase the demand for primary care and 
preventive services, and in turn increase the requirements 
for a variety of health care professionals. Primary care 
physicians, nurse practitioners, and physician assistants 
will be needed to provide preventive services, diagnosis 
and treatment for acute and chronic diseases, and serve a 
"gatekeeping" or case management function in an 
expanded managed care environment. These primary care 
providers will be essential for health system objectives of 
controlling costs, and integrating and coordinating care 
and promoting access to health care delivery. Growth of 
managed care systems such as HMOs will further increase 
the demand for primary care providers because they rely 
on these health care professionals to act as "gatekeepers" 
and to coordinate a patient's treatment, often shifting 
responsibility away from specialists. This is likely to 
increase the services of some and decrease those of other 
health care professionals. 

In addition, some types of managed care systems, such 
as staff model HMOs, frequently rely on nurse 
practitioners and physician assistant to provide primary 
care services. The growth of such systems could lead to an 
increased demand for these practitioners who are currently 
in short supply. 



Since the preponderance of specialist physicians is 
currently a factor in the escalating costs of medical care, 
and the number of medical students choosing generalist 
fields continues to decline, significant changes in the 
specialty patterns of practitioners will be required to meet 
health needs. This has been recognized by the Association 
of American Medical Colleges' (AAMC) Generalist 
Physician Task Force, which recommended "that a 
majority of graduating medical students be committed to 
generalist careers (family medicine, general internal 
medicine, or general pediatrics) and that appropriate 
efforts be made by all schools so that this goal can be 
reached within the shortest possible time." 4 

Other health personnel will be vital to provide 
increased care in ambulatory settings and within 
organized care systems of hospitals, health maintenance 
organizations, and long-term care facilities. Increased use 
of professionals experienced in community-based 
interventions and community outreach will be critical to 
ensure that all patients have true access to needed health 
care. Registered nurses and licensed practical nurses will 
continue to serve, reaching a segment of the population 
whose health care needs have been all but ignored in the 
past. Additional pharmacists would fill more prescriptive 
medications for previously untreated acute illnesses and 
for newly diagnosed chronic conditions. Pharmacists may 
also require increased time to explain the use, drug 
interactions and side effects of medications. Depending on 
the scope of State-level changes, increased access might 
also mean greater demand for dental visits since much of 
the uninsured population currently receives no dental care 
during any given year. 

Allied health personnel will be called on to perform 
additional laboratory and other diagnostic tests and 
procedures, exacerbating the existing, chronic shortage 
that exists for some of the allied health occupations. The 
1991 American Hospital Association's Survey of Human 
Resources found the highest full-time hospital vacancy 
rates were among physical therapists, occupational 
therapists, and radiation therapy technologists, with 
vacancy rates of 17, 14, and 13 percent, respectively. 5 



14 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Greater access would bring care to more individuals 
with a gamut of conditions including heart disease, 
diabetes, cancer, and HIV/AIDS; diseases which could 
affect the requirements for health care providers. In the 
case of HIV /AIDS for example, a recent study conducted 
for the Bureau of Health Professions suggests that two- 
thirds of those infected with HIV do not receive regular 
treatment for the disease— including one in nine who are 
in the final, most devastating stage. 

Supply and Training 

The Bureau of Health Professions has proactively 
emphasized the need for worksite and educational reform 
in meeting the needs of a changing health care system. 
In addition to the goal of training more generalist 
physicians, recommendations include shaping the 
workforce to reflect the nation's ethnic diversity; 
maintaining the current physician-to-population ratio 
rather than allowing it to increase; establishing supply 
needs for nurse practitioners, primary care physician 
assistants, and certified nurse-midwives; and, distributing 
physicians in a geographically equitable way. 6 

Changes in the health care system will not only alter the 
requirements for health personnel, but will also encourage 
health care professionals to care for patients in a variety of 
ambulatory or community settings. More emphasis is 
likely to be placed on ambulatory care and on longitudinal 
and preventive care services, and on outreach programs to 
draw in populations unaccustomed to obtaining health 
care services in non-emergency situations. The duties and 
scope of practice for some providers could change. HMOs, 
for example, already have concerns about the adequacy of 
graduate medical education that now occurs primarily in 
hospitals, to prepare physicians for their "gatekeeping" 
role and for practice in ambulatory and community 
settings. Similar concerns about appropriate training 
apply to specialists for whom hospital-based and 
outpatient-based practice and patient management styles 
vary greatly. 



The Pew Health Professions Commission in its 
influential first report, Healthy America: Practitioners for 
2005, found that health professions education and training 
overall is inadequate. Inadequacies exist regarding the 
type of care health professionals give, the way they give it, 
what they value and how they interact with each other, 
according to the Commission. 7 In its second report, Health 
Professions Education for the Future: Schools in Service to the 
Nation, the Pew Commission found education and training 
to be "even more out of sync with the health care system 
that is emerging." It has recommended a greater emphasis 
on values and skills such as caring for the community's 
health, ensuring cost-effective and appropriate care, and 
practicing prevention. 8 

In order for State-level health care initiatives to succeed, 
they should address issues pertaining to the education of 
the workforce, in addition to reorganization and 
refinancing. An inappropriately trained workforce will 
hinder even well planned and financed health care reform 
efforts. Access to care will not be improved if the primary 
care providers are not adequately equipped to deal with 
cultural barriers to care or are not willing to locate in rural 
and inner city areas. 

State-level health care strategies and changes in the 
health care system may influence the future supply of 
health professionals as well. These changes could affect 
scope, sites, and patterns of practice, levels of 
reimbursement for services, personal income, and 
lifestyles unevenly across the health professions. It is 
essential that policymakers at the State and Federal level 
consider the impact that these measures will have not only 
on current providers but also on incentives for individuals 
to choose health professions as careers. Changes in 
expected incomes, work environments, and working 
conditions will affect the type, quality, and number of 
individuals who will enter health professions in general 
and specific occupations in particular over the upcoming 
decades. Health care initiatives must not only be aimed at 
altering the current system but also look ahead toward 
maintaining an appropriate supply, in the context of 
epidemiologic trends and continuing technological 
development. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 15 



References 

1. Short PA, Monheit A, and Beauregard K. A profile of 

uninsured Americans. National Medical Expenditure 
Survey Research Findings. September 1989; DHHS 
Publication No. (PHA) 89-3443. 

2. Schieber GJ, Poullier JP, and Greenwald LM. U.S. health 

care expenditure performance: An international 
comparison and data update. Health Care Financing 
Review. Summer 1992; vol. 13, No. 4 pp. 1-88. 

3. Council on Graduate Medical Education. Third report: 

Improving access to health care through physician 
workforce reform: directions for the list century. 
Washington D.C.: U.S. Department of Health and 
Human Services; Oct. 1992. and Rivo ML and Satcher 
D. Improving access to health care through physician 
workforce reform: directions for the 21st century. 
Journal of the American Medical Association. September 
1, 1993;270:1074-1078. 

4. Generalist Physician Task Force. AAMC policy on the 

generalist physician, as adopted October 8, 1992. 
Academic Medicine. January 1993;68:1. 

5. Kreml BB. Survey of Human Resources-1991. Chicago, IL: 

American Hospital Association; 1992. 

6. Mullan F. Rivo ML, and Politzer RM. Doctors, dollars, 

and determination: making physician work-force 
policy. Health Affairs. Supplement 1993;12:139. 

7. Shugars DA, O'Neil EH, Bader JD. Healthy America: 

practitioners for 2005, an agenda for U.S. health 
professional schools. Durham, NC: Pew Health 
Professions Commission; Oct. 1991. 

8. O'Neil EH. Health professions education for the future: 

schools in service to the nation. San Francisco, CA: Pew 
Health Professions Commission; 1993. 



16 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Primary Care Concerns 

Robert M. Politzer, M.S., Sc.D.; 
Associate Bureau Director for Primary Care Policy. 



A Definition of Primary Care 

Primary health care includes a comprehensive range of 
public health, preventive, diagnostic, therapeutic, and 
rehabilitative services, the goals of which are to prevent 
premature death and disability, preserve functional 
capacity, and enhance overall quality of life. A wide 
variety of health professionals deliver primary medical 
care or contribute to its provision, including public health 
nurses, preventive medicine /public health physicians, 
dentists, nurses, optometrists, pharmacists, podiatrists, 
and allied health professionals. An essential component of 
primary health care, critical to an effective health care 
system, is primary medical care. Primary medical care is 
characterized by the following elements: first contact care 
for those with general health concerns; comprehensive 
basic health care not specific to an organ or a single 
problem; an orientation toward providing continuous care 
through a single provider or team of providers; and 
responsibility for coordinating other health services. 

Health professionals trained in primary medical care 
are "generalists." They are trained in, practice, and receive 
continuing education in the following competencies: 
health promotion and disease prevention; assessment/ 
evaluation of undifferentiated symptoms and physical 
signs; management of common acute and chronic medical 
conditions; and identification and appropriate referral for 
other needed health care services. Primary medical care 
providers include generalist physicians (i.e., family 
physicians, general internists, general pediatricians), 
certified nurse-midwives, physician assistants, and nurse 
practitioners. 

Economics 

Experts argue that the Nation's health care delivery 
system wastes enormous amounts of money on marginal, 
duplicative, and unnecessary services. 1 The prevalence of 
open-ended funding through indemnity insurance and fee- 
for-service reimbursement of providers and hospitals is a 
powerful stimulus to provide extra services of all kinds, 
including many of marginal benefit. A system that does 
not require or encourage patients to see generalists before 
going to specialists, and reimburses those specialists at a 



preferred rate, uses far more tertiary services and is far 
more costly. 1 Any attempt to change the educational 
environment to promote generalism will be thwarted by 
the absence of changes in how care is delivered and 
reimbursed. The Resource-Based Relative Value Scale, 
adopted for reimbursement under Medicare, is an attempt 
to shift reimbursement in favor of promoting primary care. 
However, changes in the structure of the reimbursement 
system must be more pervasive, involving other payers, to 
effectively stimulate the production of generalists. 

Educational Environment 

Comprehensive educational changes are essential for 
redirecting health professions training toward greater 
generalism, including changes in the financing of 
undergraduate and graduate health professions education. 
Other necessary changes include the training and 
deployment of primary medical care providers in addition 
to generalist physicians, restructuring academic 
admissions procedures, revamping the system of 
accreditation, expanding community-based ambulatory 
training experiences, focusing on the organization and 
management of services, enhancing outcomes research, 
expanding primary care faculty development activities, 
retraining and reorienting specialists to be primary care 
providers, and increased access to the underserved. 

Financing of Undergraduate and Graduate 
Health Professions Education 

Health professions education receives substantial 
support from tax dollars. The most visible but least 
substantial Federal contribution, at $287 million in fiscal 
year 1992, is made through programs under Titles VII and 
VIII of the Public Health Service Act. This includes 
funding for primary care training, and loan and 
scholarship programs for financially needy and minority 
students. The Departments of Defense and Veterans 
Affairs administer graduate medical education programs 
costing more than $750 million together. The National 



1993 • Health Personnel in the United States • Ninth Report to Congress • 17 



Institutes of Health (NIH), although not expressly 
authorized to finance health professions education, 
indirectly influences the educational environment by 
supporting specialization through its biomedical research. 2 
The NIH budget exceeded $10 billion in fiscal year 1993. 

The Medicare trust fund pays hospitals in excess of $5 
billion per year for graduate health professions education. 
About one-third covers the direct reimbursement of 
medical residents and nursing and a variety of allied 
health students trained in the hospital environment. These 
dollars, driven by the number of residents and students 
and Medicare days-of-care rates for hospitals, support 
hospitals' acute care, high-tech service needs for labor and 
undermine the preparation of generalists. These dollars 
need to be reallocated to support generalist training and 
primary care training in community-based settings. 3 

Deployment of Generalists Other than 
Physicians 

Analysis of the current health workforce, as well as 
projections of demand given present and likely future 
changes in the health care delivery system, need to take 
into account the substantial presence and potential future 
contribution of nurse practitioners, physician assistants, 
and certified nurse-midwives. These non-physician 
providers have traditionally practiced primary care, 
although today there is a tendency for physician assistants, 
in particular, to work in specialty settings. A number of 
studies have concluded that non-physician providers with 
advanced education are seriously underutilized in today's 
health care system. 4 The reasons include legal scope of 
practice restrictions, delegation, unfavorable 
reimbursement policies, and the small size of existing 
training programs. The net effect is that fewer services are 
delivered at higher prices than necessary. One research 
team estimates that $6 billion to $8 billion is lost from the 
current inefficient use of primary care nurse practitioners. 4 



Restructuring Academic Admissions 
Procedures 

Current admissions criteria need to be redirected to 
select students who are more likely to practice in 
underserved areas, and to reverse the trend away from 
interest in primary care careers. The evidence suggests 
that those from racial/ethnic minorities and rural 
backgrounds are more likely to select primary care careers 
and practice in underserved locations. 2 The composition of 
admissions committees also needs to reflect the desired 
generalist /specialist workforce mix. 

Revamping the Accreditation Process 

The current system of accreditation, certification, and 
licensure has contributed to the generalist/specialist 
imbalance. These specialist-dominated, uncoordinated, 
and often contentious bodies have reinforced the current 
educational paradigm and have been unresponsive to the 
kinds of primary care providers needed for the future. 27576 
This system needs to be simplified and coordinated to 
remove barriers to practice that inhibit access to health 
care for millions of Americans. 



Figure 1 

After Declining, Interest in 
Primary Care Careers Has Grown 






1981 1992 



Medical School Seniors Planning to become 
Board Certified in a Primary Care Specialty 



1994 



18 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Expanding Community-based Ambulatory 
Training 

The dominance of hospital-based tertiary care training 
has been cited as one factor that has contributed to the 
erosion in primary care career selection. 778 Training 
experiences must mirror the settings in which primary care 
providers are most likely to practice. Community-based 
ambulatory training experiences teach future practitioners 
to assess the service needs of the potential patient 
population. The amount of curriculum time devoted to 
these settings is a factor that influences career choices. 
Required experiences in community-based settings are 
therefore necessary to balance the dominance of more 
narrow, specialized training. 27778 

Organization and Management of Services 

The new and emerging health care delivery system 
with emphasis on managed care arrangements necessitates 
expansion of primary care services. However, without a 
concurrent restructuring of the system in which primary 
care services are delivered, the prospects for improving 
access while controlling costs will be limited." In essence, 
the organizational structure in which much of primary 
care will be delivered, such as in managed care 
arrangements, creates a level of hierarchy and 
accountability where the primary care provider will be the 
usual source of care, manage a variety of patient concerns, 
and control the referral process to specialists. The 
education of primary care providers must prepare these 
future practitioners to work in a variety of organizations 
and to manage the allocation of resources. 

Enhancing Outcomes Research 

Research activities in clinical patient care, primary care 
education, and health services delivery should be an 
integral part of the research agenda of health professions 
schools and faculty. Medical effectiveness outcomes 
research should continue to focus on primary care 
procedures and interventions to establish their efficacy 
and efficiency. 



Faculty Development 

Faculty often are role models for students and influence 
student career choices. 10/7/8/ Serious efforts must be 
made to develop interdisciplinary faculty with a 
commitment to changing the milieu of health professions 
schools. Curriculum and admission criteria changes, and 
even fiscal changes, will have to be preceded by faculty 
development. In addition to exposing university and 
program-based faculty to community care delivery 
settings, more community-based care providers will have 
to be trained as faculty. 

Service to the Underserved 

Differences in health status between the "haves" and 
"have nots" of the nation's population continue to be an 
embarrassment. Delivering adequate and appropriate 
primary care services to those who currently do not have 
access is a critical factor in narrowing and eliminating 
these differences. Future primary care providers must be 
exposed to and trained in delivery settings that serve these 
populations. 2 

Retraining and Reorienting 

The necessary changes in the generalist/ specialist 
workforce mix to meet the requirements of a changing 
health care delivery system cannot come from the pipeline 
of provider production alone. Reorienting and retraining 
specialist providers already in practice offers the most 
direct approach. Redirecting the careers of providers in 
mid-course is a sizeable hurdle. However, in a health care 
delivery system that emphasizes the primary care provider 
as the primary source of health care and the manager of 
specialty referral, many specialists may seek to change 
their practice. Mid-career training programs should be 
established and focus on skill-building in the clinical 
disciplines of primary care as well as on the capabilities 
required of providers in managed care settings. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 19 



The Role of Other Health Care Providers 

Policy targets for primary care supply, distribution, and 
generalist/ specialist mix among other health care provider 
pools need to be established based upon population needs 
and cost containment. Although a consumer's inability to 
pay for services is believed to play a substantial role, the 
extent to which increasing specialization contributes to the 
unavailability of services from dentists, pharmacists, 
podiatrists, and optometrists, for example, is not known. 
Evidence does suggest that dental graduates are 
specializing more than ever before." Pharmacists are 
among the most evenly distributed health professionals 
when measured against population, and could be a source 
of first contact care for individuals without any alternative. 
However, it is not clear the extent to which current 
pharmacy training prepares its graduates for such a role. 

The Role of Government 

Organized delivery systems, such as managed care 
arrangements, can provide health care for less than the 
cost of piecemeal fee-for-service care. Public entities need 
to influence this change by removing barriers and 
disincentives to the full use of primary care providers. 
Yet, they must also protect the quality of care. Health 
professions education will have to be restructured to meet 
the demands of health care. Restructuring will not require 
major new expenditures, however; the current system 
already devotes substantial resources to health professions 
education. 



References 

1. Relman A. Reforming our health care system: a 

physician's perspective. The Key Reporter. 1992;58:1-5. 

2. Council on Graduate Medical Education. Third Report- 

Improving Access to Health Care through Physician 
Workforce Reform: Directions for the 21st Century. 
Washington, D.C.: Department of Health and Human 
Services. October 1992. 

3. Mullan F. Missing: a national medical manpower policy. 

The Milbank Quarterly. 1992;70(2):381-386. 

4. Nichols L. Estimating costs of underusing advanced 

practice nurses. Nursing Economics. 1992;10(5):343-351. 

5. Martini C. Graduate medical education in the changing 

environment of medicine. Journal of the American 
Medical Association. 1992;268(9):1097-1105. 

6. Physician Payment Review Commission. Annual Report 

to Congress, 1992. Washington, D.C.: 1992; pp. 303-305. 

7. Politzer R, Harris D, Gaston M, Mullan F. Primary care 

physician supply and the medically underserved: a 
status report and recommendations. Journal of the 
American Medical Association. 1991;266(1):104-109. 

8. Colwill J. Barriers to an enhanced linkage between 

education and service: education of physicians to 
improve access to care for the underserved. In: 
Proceedings of the Second Health Resources and 
Services Administration Primary Care Conference. 
Columbia, MD; March 21-23; pp. 319-25. 

9. Simmons H, Rhoades M, Goldberg M. Comprehensive 

health care reform and managed competition. New 
England Journal of Medicine. 1 992;237(21 ) : 1 525-1 528 . 

10. Colwill J. Where have all the primary care applicants 

gone? New England Journal of Medicine. 
1992;326(6):387-393. 

11. Bureau of Health Professions. Health Personnel in the 

United States, 1991: Eighth Report to Congress. 
Washington, D.C.: Department of Health and Human 
Services; September 1992. DHHS Pub. No. (HRS-P- 
OD-92-1). 



20 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Analysis of Selected Barriers to Expansion of 

Clinical Practice by Nurse Practitioners 

and Certified Nurse-Midwives 



Nurses in "advanced practice" consist of certified 
nurse-midwives (CNMs), nurse practitioners (NPs), 
clinical nurse specialists (CNSs), and certified registered 
nurse anesthetists (CRNAs). The Division of Nursing's 
March 1992 National Sample Survey of Registered Nurses 
(NSSRN) estimates there are approximately 139,000 
registered nurses with formal preparation as "advanced 
practice nurses." These represent about 6 percent of the 
2.2 million nurses licensed to practice. About 42 percent, 
or 58,000, of the advanced practice nurses were CNSs with 
master's degree preparation. Another 35 percent, or 48,200, 
were NPs. Among the remaining advanced practice nurses 
were some 25,000 nurse anesthetists, of whom 21,000 were 
certified, and some 7,400 nurse-midwives, of whom about 
5,000 were certified. Eighty-seven percent of the advanced 
practice nurses were employed in nursing, although not 
always with an advanced practice title. 1 



Figure 2 

Registered Nurse Population with 
Advanced Practice Preparation, 1992 

7,400 Nurse Midwives 




Total: 139,000 
6% of the 2.2 Million RN Population 

Source: HRSA, BHPr, DN; National Sample Survey of R.N.s. 



Irene SandvoU, DrPH, MSN, CNM 

While each of these "advanced practice" nurse groups 
contribute significantly to the health care of the 
population, concerns about the availability of primary care 
has led to a particular focus on NPs and CNMs. Recent 
policy papers have included recommendations to extend 
and expand their practice to improve the health of the 
population and to meet the national Healthy People 2000 
objectives. These recommendations are to expand the 
number and distribution of NPs and CNMs. 2/3/4/5 Other 
recent articles have presented economic models to estimate 
some of the costs to society when nurses in advanced 
practice (NPs, CNMs, and CNSs) are not fully integrated, 
or are underutilized, in the health system. 576 

A number of barriers inhibit the full scope of practice of 
advanced practice nurses, thus preventing optimal 
provision of primary health care services to the 
population. The focus of this discussion is on NPs and 
CNMs, although some of these barriers also are relevant to 
the practice of CNSs and CRNAs. These barriers include 
restrictive practice legislation; limited ability to prescribe 
and dispense drugs; infrequent or inadequate 
reimbursement for care provided; physician resistance; 
inability of current educational programs to produce 
sufficient numbers of graduates; increasing malpractice 
insurance rates or lack of coverage; and barriers related to 
the health care system itself. 3/7/8/9/10 

Legislation 

Some authors consider the major barrier to be the 
restrictive State provisions governing scope of practice and 
prescriptive authority. Safriet, for instance, notes that 
restrictive nursing legislation does not accommodate the 
changing boundary between the practice of medicine and 
nursing. 8 



1993 • Health Personnel in the United States • Ninth Report to Congress • 23 



Scope of Practice 

Most States require licensure and national certification 
of NPs and CNMs. State laws are inconsistent, however, 
regarding the scope of nursing practice. Activities that 
may be sanctioned in one State without physician 
intervention, approval or protocols, may not be allowed in 
another. To date, although most States have legally 
acknowledged the practice of NPs and CNMs, most have 
restrictions limiting their scope of practice. Some of the 
restrictions result from the fact that the titles and scope of 
practice used in the legislation often do not match the 
variety of NPs and position titles found in practice, i.e., 
nurse clinician, NP, advanced practice, and a variety of 
specialty titles. This lack of uniformity in title is confusing 
to policymakers and insurance carriers and does not reflect 
the increasing national uniformity in educational 
preparation, examinations to assure competence, and 
practice. 

Often regulations are made through joint action of the 
Board of Nursing and the Board of Medicine, or by joint 
committees comprised of NPs, CNMs, MDs, and 
pharmacists. Safriet points out that "even when a 
legislature has sanctioned advanced practice nursing, 
much depends upon the body charged with subsequently 
elaborating the scope of practice." She notes that there is a 
strong possibility that anti-competitive motives will dictate 
restrictions that are not justified on public safety grounds 
when the task of developing regulations is delegated to 
mixed-regulators. In addition, other disciplines may not 
understand the educational preparation or full scope of 
practice of NPs or CNMs. 8 Safriet also points out that other 
professions are licensed by boards composed of their 
colleagues. Likewise, she states, the regulation of nursing 
should be carried out by each State's Board of Nursing 
(BON). A multiprofessional approach to regulation has 
the potential for bias stemming from professional 
territoriality, and financial and competitive concerns. 



Restrictions on the scope of practice found in various 
State laws and regulations generally center around formal 
relationships with physicians spelled out in written 
practice agreements, protocols, collaborative guidelines. 
They also center around requirements for physician 
direction and /or supervision. They include restrictions of 
practice to certain facilities or geographic areas. They may 
vary in terms of nature of the required physician 
collaboration; i.e., whether the physician needs to be 
physically present in the room where care is being 
provided, within vocal range, on the premises, or available 
by telephone. However, these State restrictions often do 
not apply when the NP or CNM practices in a rural or 
inner city clinic within the State. 

Innovative use of telecommunication and information 
systems may be inhibited by such regulations. With 
current communication technology, consultation and co- 
management of clients /families /and certain conditions 
often can be effectively accomplished by telephone, 
computer or conference call in the absence of a physician. 
Such restrictions limit the scope of practice of NPs and 
CNMs and their ability to increase access to quality care. 



22 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Prescriptive Authority 

The major policy question is whether a State will 
acknowledge and authorize the prescribing practices of 
NPs and CNMs. 

Prescription authority (prescription of drugs and other 
treatments) of NPs and CNMs also varies from State to 
State. The first State provision for limited prescriptive 
authority for NPs was in 1975 and for CNMs in 1977. 
Currently, explicit statutory or regulatory provisions exist 
in more than 40 States. However, these authorizations 
vary in the degree of independence they afford, and in the 
types of drugs and devices which may be prescribed. 
Many States restrict prescriptive activity in similar ways as 
for scope of practice, i.e., by geographic or practice 
settings. Others impose requirements for written protocols 
and /or physician supervision or direction. The changing 
nature of pharmacological intervention counsels against 
rigid statutory restrictions. 8 

Restrictions on prescriptive authority can make it 
difficult for NPs and CNMs to obtain the Federal Drug 
Enforcement Administration (DEA) registration required 
to prescribe, administer or dispense controlled substances. 
In addition, because some insurance companies use DEA 
numbers as provider identifiers for reimbursement, NPs 
and CNMs who do not have their own registration 
number are prevented from gaining reimbursement from 
these companies. Controlled substances are defined by the 
Federal Controlled Substances Act of 1970, which requires 
that dangerous drugs be included in a list of "schedules" 
prepared by the Federal Drug Administration (FDA). 
Dangerous drugs are those with no accepted use, a 
significant potential for abuse because of their addictive 
properties, or major psychoactive properties. The 
schedules, I - V, rank drugs by their potential for addiction 
and abuse. 



The DEA issues registration numbers to all providers 
authorized to prescribe, dispense, administer or conduct 
research with controlled substances under the laws of the 
State in which they practice. To address this issue, the 
DEA has issued the final rules regarding the registration of 
"midlevel practitioners," including CNMs and NPs if they 
are authorized to dispense controlled substances by the 
State in which they practice. 11 If registered, advanced 
practice nurses would be able to dispense controlled 
substance schedules II-V as directed by State law, 
regardless of their collaborative arrangement. 1278713 
Some State regulations restrict the schedules of drugs 
NPs or CNMs are permitted to prescribe to those with less 
potential for abuse and with more certain therapeutic 
applications. 

Payment 

State and Federal reimbursement laws determine which 
services are reimbursable; whether those services are 
consistent with the NP's or CNM's scope of practice; the 
amount of reimbursement, and whether that amount is the 
same or different from that provided to physicians. The 
Federal government generally sets the pattern for other 
insurers and the States. Federal law has mandated direct 
Medicaid reimbursement for CNMs since 1980, and for 
pediatric nurse practitioners (PNPs) and family nurse 
practitioners (FNPs) since 1989, whether or not they are 
directly supervised by a physician. The State legislation in 
general follows Federal guidelines for programs funded by 
the Federal government. 

Some States are not in compliance with Federal 
legislation. Currently, NPs are eligible to receive direct 
third-party reimbursement in 38 States; however, only 24 
States have legislatively mandated third-party 
reimbursement. 12 CNMs are eligible for third-party 
reimbursement in 27 States. 14 The NPs and CNMs are 
reimbursed according to the State legislative framework. 



2993 • Health Personnel in the United States • Ninth Report to Congress • 23 



Whether reimbursement can be made directly to the 
provider, the facility, or is to be billed through a physician 
affects autonomy and independent practice. While PNPs 
and FNPs can be reimbursed directly for the Medicaid 
services they provide; other NPs such as those focusing on 
care of adults, women, and school-age children, cannot. 
Many of these NPs provide needed care to the same 
population as those who are reimbursed by Medicaid. 
Expansion of reimbursement to additional types of NPs, 
and for a wider range of populations and conditions, 
would increase access to quality care. 

FNPs and PNPs also have barriers to reimbursement in 
States where the statute for advanced nurse practitioners 
does not designate FNP or PNP as specific titles. 

Some States have laws requiring private insurers to 
reimburse NPs for their services; but often this coverage is 
optional. Although NPs and CNMS are eligible to receive 
some form of direct, third-party reimbursement in all 50 
States, until recently most private insurance companies 
had not expanded coverage to include NP or CNM 
services. NPs and CNMs may have to convince each 
employer and each private insurance carrier of the need 
for coverage when an employer negotiates a plan for their 
employees with a private insurance carrier. Without 
specific State legislation, some insurers refuse to offer 
reimbursement. In addition, self-insured companies are 
exempt from the mandated coverage requirement. These 
companies often cite their option to use their business 
judgment with regard to which providers will be 
reimbursed. 8715 Further, they often do not cover primary 
and preventive care, which offer the possibility for 
significant improvement in health status and frequently 
are delivered by NPs and CNMs. 



Where covered, Medicare restricts payment to 65 
percent of the physician fee schedule, unless the NP or 
CNM is working in services funded through the Rural 
Health Clinics Act. In 1993, CHAMPUS began 
implementation of Medicare payment policies. However, 
some major Federal Employee Health Benefit plans 
eliminated NPs and CNMs as preferred providers by 
major carriers, which means that the Federal employee 
who wants care from those providers must pay additional 
fees to receive it. 15/16 

The States have broad discretion in determining fee 
levels and payment methods. There are also limits on 
reimbursement amounts based on a percent of a 
physicians' fee schedule. Medicare Part B services have 
been reimbursed following the "reasonable charge 
payment" concept. In 1989, based on the recommendation 
of the Physicians Payment Review Commission (PPRC), 
Congress mandated the development of a fee schedule to 
replace the reasonable charge system and directed the 
PPRC to study the implications of including 
"nonphysician providers" (NPPS) in the fee schedule. The 
ACNM requested the PPRC to wait for the results of a 
Robert Wood Johnson funded study on CNM care to 
vulnerable populations before determining reimbursement 
rates. Issues of cost containment and unique care 
provided by NPs and CNMs are under review 17 

The Resource-Based Relative Value Scale (RBRVS) 
carries with it further potential problems for NPs seeking 
Federal reimbursement, and is part of the complex 
discussions on cost containment. 8 



24 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Relationships With and Understanding 
by Physicians and Others 

Major barriers to full use of NPs and CNMs are lack of 
knowledge and resistance on the part of physicians, both 
generalists and specialists, to their full participation on the 
health care team. 7/8 The National Health Service Corps 
(NHSC) has experienced delays and problems in 
identification and development of appropriate placements 
for students who have been awarded scholarships and 
graduates who have agreed to the loan repayment 
program in exchange for working in an underserved area. 
This difficulty in placement can be expected, because 
unless a group of providers, or a community, has worked 
with an NP or CNM, they often do not fully understand 
the potential benefits of adding an NP and/or CNM to 
their interdisciplinary health care team. 

The Federal Trade Commission (FTC) has acted to stop 
boycotts aimed at limiting competition among health-care 
providers, analyzed issues relating to the denial of hospital 
privileges to NPs and CNMs, and scrutinized State and 
Federal statutes and regulations for anti-competitive 
provisions. The FTC's initiatives which have involved 
CNMs have centered on hospital privileges, malpractice 
insurance for backup physicians, and third-party 
reimbursement. 

Current Work in Progress 

Several studies designed to provide insight into the 
nature of these practice barriers are underway. 
Information derived from them is expected to assist 
policymakers in developing strategies to alleviate some of 
the barriers. 

Recent studies about barriers to nurse-midwifery care 
indicate a lack of knowledge about nurse-midwifery care 
among both the public and policymakers. 779 Steps 
recommended to eliminate barriers included studies that 
both document the contributions of nurse-midwives to 
vulnerable populations, and the effect of these 
contributions on health-care costs. 7 A current, ongoing 



American College of Nurse-Midwifery study, funded by 
the Robert Wood Johnson Foundation, is designed to 
provide data on nurse-midwifery care, with particular 
attention to vulnerable populations. The impact of 
legislation and reimbursement policies on the populations 
served, the nature of the services provided, the fees 
charged, and the total costs of care are addressed in this 
study, along with other actual and potential barriers. 18 

Information on the nation's supply of NPs will be 
updated by a Division of Nursing study designed to 
determine the number of registered nurses in the United 
States with certification as a NP or CNS; to examine the 
type, nature, and location of their practices; to identify the 
populations they serve; and to describe professional 
characteristics. 

The Division of Nursing also is carrying out a project 
to examine the parameters of the practice roles of NPs and 
CNMs and other factors that need to be considered in 
developing projections of the number required in the 
future. Subsequently, the Division plans to examine these 
projections in relation to the number of CNMs and NPs 
anticipated to be available. 

Conclusion 

Issues related to State and Federal practice barriers 
affect the ability of NPs and CNMs to increase access to 
quality care. The nature of the practice of NPs and CNMs, 
which addresses primary health care and prevention, and 
which centers on the client's/family's strengths and 
priorities, can, in the long term, help reduce health care 
costs, improve access to quality health care and promote 
positive health outcomes. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 25 



References 

1. Bureau of Health Professions, Division of Nursing. The 

Registered Nurse Population, March 1992: Findings from 
the National Sample Survey of Registered Nurses. 
Washington, D.C.; U.S. Department of Health and 
Human Services; May, 1993. (to be published) 

2. Committee to Study the Prevention of Low Birth Weight, 

Institute of Medicine. Preventing Low Birthweight. 
Washington, D.C.: National Academy Press, 1985. 

3. Office of Technology Assessment. Nurse Practitioners, 

Physician Assistants and Certified Nurse-Midwives: A 
Policy Analysis. Washington D.C.: Congress of the 
United States; December 1986. Health Technology 
Case Study 37. 

4. National Health Service Corps. The National Health 

Service Corps White Paper, Proposed Strategies for 
Fulfilling Primary Care Professional Needs: Part II: Nurse 
Practitioners, Physician Assistants, and Certified Nurse- 
Midwives, 1991. Washington, D.C.: Department of 
Health and Human Services;1991. 

5. Nichols L. Estimating costs of underusing advanced 

practice nurses. Nursing Economics. 1992;10(5):343- 
351. 

6. McGrath S. The cost-effectiveness of nurse practitioners. 

Nurse Practitioner. 1992;15(7):40-42. 

7. Rooks J, Haas JE. Nurse-Midivifery in America. A Report of 

the American College of Nurse-Midioives Foundation. 
American College of Nurse-Midwives Foundation, 
Inc., 1986. 

8. Safriet B. Health care dollars and regulatory sense: the 

role of advanced practice nursing. The Yale journal on 
Regulation. 1992:9(2):149-220. 

9. Office of Inspector General. Survey of Certified Nurse- 

Midwives. Washington, D.C.: Department of Health 
and Human Services; March 1992. (OEI-04-90-02150) 



10. Office of Inspector General. Enhancing the Utilization of 

Nonphysician Health Care Providers and Enhancing the 
Utilization of Nonphysician Health Care Providers: Three 
Case Studies. Washington, D.C.: U.S. Department of 
Health and Human Services. April, 1993. (OEI-01-90- 
02070) 

11. Federal Register Vol. 58, NO103/Tuesday, June 1, 1993, 

pp 31171-31175. 

12. Pearson L. 1992-1993 update: how each state stands on 

legislative issues affecting advanced nursing practice. 
Nurse Practitioner. 1993;18(l):23-38. 

13. Fennell K. Prescriptive authority for nurse-midwives: a 

historical review. Nursing Clinics of North America. 
1992;26(2): 511-522. 

14. Bidgood- Wilson M. The legislative status of nurse- 

midwifery: Trends and future implications. Journal of 
Nurse-Midwifery. 1992;37(3):159-160. 

15. Barickman C, Bidgood-Wilson M, Ackley S. Nurse- 

midwifery today: a legislative update, journal of 
Nurse-Midwifery, Part 1, 37(2), 43-118, and Part II, 37(3), 
175-209. also Political and Economic Affairs 
Committee. Nurse-Midwifery Today: A Handbook of State 
Legislation. American College of Nurse-Midwives. 
1992. 

16. Blue Cross and Blue Shield. A Bulletin from Provider 

Services. Blue Cross Blue Shield. December, 1992. 

17. Edmunds M. Lack of evidence could exclude NPs from 

reimbursement-reform legislation. Nurse Practitioner. 
1991:8. (citing PPRC open meeting, Feb. 1991.) 

18. Scupholme A, Dejoseph J, Strobino D, Paine L. Nurse- 

midwifery care to vulnerable populations phase I: 
demographic characteristics of the national CNM 
sample. Journal of Nurse-Midwifery. 1992;37(5):341-348. 



26 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Barriers to Physician Assistant Practice 



Joyce W. Emelio, Division of Medicine, BHPr. 



Physician assistants (PAs) are educated as primary care 
generalists in programs that follow a medical model of 
patient care. Upon graduation they are prepared to 
practice medicine under the supervision of a licensed 
physician, providing patients with services ranging from 
primary to highly specialized surgical care. 

Studies such as the 1986 Office of Technology 
Assessment (OTA) report have concluded that PAs 
improve access to primary health care and that the quality 
of care they provide, within their skills and competencies, 
is equivalent to that of physicians. In addition, the OTA 
report found that "the use of PAs results in productivity 
gains and cost reductions." 1 Although major strides have 
been made in removing barriers to their practice, obstacles 
remain that prevent them from using their skills to the 
fullest. These obstacles include restrictive State medical 
practice laws and regulations, particularly the lack of 
prescribing privileges, and inconsistent State Medicaid and 
Medicare reimbursement policies. 

Physicians conceived and fostered the idea of PA 
practice in the mid-1960s. It is not surprising, then, that 
physicians generally accept PAs. 2 For their part, PAs are 
committed to the team approach to patient care in which 
each profession is recognized for its unique skills and 
contributions. Unlike nurse practitioners, who seek 
greater autonomy, PAs believe the most appropriate and 
logical individual to supervise the health care team is the 
physician. 3 

PAs' scope of practice is determined by several factors: 
State laws and regulations, the supervising physician's 
delegation of responsibilities, the PAs education and 
experience, and the specialty and setting in which they 
work. Not all States allow PAs to participate in the system 
that regulates them. In those that do, PA participation 
occurs through their having seats on medical licensing 
boards; on PA committees to those boards; or through the 
creation of separate PA licensing boards. Where PAs take 
part in regulating their profession, they tend to have 
acquired greater autonomy and a broader scope of 
practice, especially in rural and remote settings. 4 



State Legislative/Regulatory Issues 

By 1992, all States except Mississippi had enacted laws 
and /or regulations recognizing PAs. Recognition serves 
two main purposes: (1) to protect the public from 
incompetent performance by unqualified PAs, and (2) to 
delegate the appropriate tasks to PAs. 5 

Specific elements in statutes and regulations that 
facilitate the best use of PAs include standardized 
qualifications for PAs; supervision requirements in which 
the particulars are left to the physician /PA team; the 
absence of requirements for on-site physician supervision; 
a scope of practice including any task delegated by a 
physician and within the PA's skills and competencies; 
unlimited prescribing authority as well as limited 
authority to dispense drugs, especially in remote areas that 
may not have a pharmacy; and some provision for 
temporary licensure. 6 

A PA's standard qualifications, endorsed by the 
American Academy of Physician Assistants (AAPA) and 
adopted by all but a few States, include two criteria: (1) 
graduation from a PA program accredited by the American 
Medical Association's Committee on Allied Health 
Education and Accreditation, and (2) successful passage of 
the national certifying examination administered by the 
National Commission on Certification of Physician 
Assistants (NCCPA). 5 

Supervision Requirements 

Although PAs are always legally under the supervision 
of a physician, the definition of supervision varies widely. 
Forty-two States, including the District of Columbia, allow 
physicians to supervise PAs without being on the 
premises. 7 Such a provision is critical if PAs are to be used 
most effectively in areas underserved by physicians. 

Overly restrictive supervision provisions found in State 
laws and regulations have resulted in limits being set on 
the number of supervisors a PA may have; limits on the 



1993 • Health Personnel in the United States • Ninth Report to Congress • 27 



number of PAs a physicians may 
supervise; requirements that the 
physician be on site at all or most of the 
time; and a burdensome amount of 
paperwork on physicians before they can 
hire PAs. 8/9 

Scope of Practice 

Those who developed the concept of 
physician assistant envisioned the scope 
of practice for these professionals as 
being determined solely by their 
physician supervisor. Nonetheless, since 
the 1970's, States gradually have 
established and increased their own 
restrictions. 6 Such restrictions may cover 
procedures or responsibilities; lists of 
authorized tasks; requirements for 
separate board approval of procedures 
not on the list; and requiring the 
supervising physician's to submit 
elaborate job descriptions, utilization 
plans, and protocols. 



Prescriptive Authority 

Thirty-five States, the District of Columbia, and Guam 
allow PAs to prescribe medications. 10 Two-thirds of these 
States allow PAs to prescribe controlled substances. 

In 1993, PAs had 152 million patient contacts and wrote 
an estimated 175 million prescriptions." Seventy-one 
percent of all PAs and 83 percent of those in rural areas 
practiced in States granting prescriptive authority. 12 

States that grant prescriptive authority, however, may 
limit it to non-controlled substances or drugs on a board- 
approved formulary. 9 Patient management, especially in 
remote satellite settings, is severely hampered without the 
ability to prescribe a full range of medications. PAs who 
practice in States without this authority tend to be 
restricted to subspecialties and inpatient settings. 1279 



Figure 3 

Physician Assistants' 
Prescribing Authority by State 




•As of July 1993 

Source: Physician Assistants - Prescribing and Dispensing, American Academy of Physician Assistants, July 1993. 
Reprinted with permission of the American Academy of Physician Assistants. 



Paradoxically, States without prescriptive authority also 
appear to be those in greatest need of primary care 
services. In 1988, 7 million of the 16 million rural residents 
who lived in Federally designated primary care Health 
Professional Shortage Areas (HPSAs) resided in a cluster 
of Southeastern and Midwestern States without 
prescriptive authority. 12713 

The AAPA has conducted an analysis of practice 
patterns in Montana and Texas, where prescriptive 
authority did not exist in 1989, but was subsequently 
implemented. In Montana, 34 PAs were practicing in 1989. 
By 1992, two years after they won prescriptive authority, 
their numbers had nearly tripled to 96. In 1989, only 5 
percent of PAs in Texas were practicing in rural 



28 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Figure 4 

Distribution of PAs in Rural Practice by 
State Laws on Prescribing Authority 

72.88 



53.88 




Prescribing Authority 



Regulations Pending 



No Prescribing Authority 



j Population greater than 10,000 
! ] Population less than 10,000 



Source; Willis, J. Barriers to PA Practice in Primary Care and Rural Medically Underserved Areas. 

Journal ol the American Academy ol Physician Assistants. June 1993. 

Reprinted with permission of the author. 



communities. However, after passage of prescribing 
legislation, and the subsequent approval of the use of PAs 
in rural clinics, the percentage increased to 15 percent. 12 

Temporary Licensure/Locum Tenens 

Some 37 States have a provision for temporary licensure 
of new PA graduates while they wait to take the NCCPA 
examination or to receive examination results. Because a 
majority of recently graduated PAs have incurred 
education-related debt and many are older adults with 
families to support, it is unreasonable to expect that they 
remain unemployed in their field for a lengthy period of 
time. The test typically is offered in November, often 6 
months after graduation, and the results are not available 
until January or February. 



For the past two years, PA students have 
been eligible for the National Health 
Service Corps (NHSC) Scholarship 
Program which requires that upon 
graduation, they work in a medically 
underserved site. However, since the 
NHSC requires that the scholarship 
recipients comply with the laws of the State 
in which they are to practice, and the 
NCCPA examination is given several 
months after graduation, newly graduated 
PAs could be forced to find employment 
elsewhere, and could be in danger of 
defaulting on their NHSC service 
commitment. 



Temporary licensure might also facilitate 
the hiring of locum tenens substitutes to 
replace PAs for brief periods of time. Like 
physicians, PAs are reluctant to work in 
rural areas where back-up coverage is 
scarce and the potential for burn-out 

high _15/16/17 

Recognizing the increased potential for 
"burnout" among PAs and to address the 
other disincentives associated with 
attracting PAs to'rural practice, some States 
such as Montana have authorized temporary duty licenses 
to be used to hire replacements when permanent PAs take 
vacation or complete continuing medical education (CME) 
credits. 17 This is of increased importance to PAs, since they 
are to complete 100 hours of CME credits every 2 years 
and take a recertification examination every 6 years in 
order to maintain certification. 

The vast majority of States, however, either do not have 
a locum tenens system in place for PAs, or have a system 
that requires an unreasonable amount of advance notice or 
excessive paper work for approval to practice as a 
substitute. 9 



1993 • Health Personnel in the United States • Ninth Report to Congress • 29 



Medicare/Medicaid Reimbursement 
Regulations 

Medicare 

Medicare Part B policies provide uneven 
reimbursement for PA primary /ambulatory care services 
from State to State, because carriers choose to interpret 
regulations differently, particularly the "incident to" 
clause. Reimbursement of PA services in hospitals is less 
problematic, since Medicare Part A covers the services of 
hospital employed PAs. The law also allows hospitals to 
bill for PA services under Part B, although hospitals cannot 
bill for the same service under both. 

While Medicare Part B coverage of physician services 
provided by PAs is clearly allowed in hospitals, nursing 
homes and rural HPSAs, confusion arises in the case of 
outpatient services delivered in rural areas that are not 
designated as HPSAs and in urban areas. In these 
locations, services provided by PAs may be billed under 
the "incident to" provisions of Medicare regulations. 
"Incident-to" services are those which are typically 
performed in a physician's office, under his/her direct 
supervision and billed as part of the physician's overall 
charges. However, private carriers have not consistently 
interpreted what services (if any) they will cover under 
this language. The "incident to" provision also has 
stricter supervision requirements than exist in many State 
laws. 

Since the PA's scope of practice and the physician's 
scope of practice overlap, the definition of covered services 
has become muddled. Many carriers began permitting 
physicians to bill for any service provided by a PA as long 
as the supervising physician was in the building. Others 
continue to limit coverage to services such as injections 
and blood-pressure checks. The lack of consistency among 
carriers has caused considerable confusion both for 
physicians and PAs and has discouraged some physicians 
from hiring PAs. 23 



There is also considerable variation in the Medicare 
reimbursement for services provided by PAs in all settings. 

All Medicare reimbursement goes to the employing 
practice, facility or physician, not to the PA. PAs do not 
seek to have Medicare reimburse them directly for their 
services based on the belief that this would compromise 
the PA /physician relationship and deter clinics and 
hospitals from hiring them. If, however, the Health Care 
Financing Administration law made reimbursement for PA 
services identical in all settings and removed the "on-site" 
physician supervision requirement, it would reduce the 
complexities and paperwork associated with the 
reimbursement process for employers. 

Medicaid 

In principle, 41 States cover PA services under their 
Medicaid program. More than half, however, lack specific 
regulations to determine which services are covered. 20 The 
fact that no Federal Medicaid mandate (other than the 
Rural Health Clinic Services Act) requires States to cover 
PA services may have influenced these States not to have 
developed specific regulations for PA coverage. 20 

Medicaid programs typically cover PA services as long 
as these services are covered by their plans when provided 
by a physician, but the Medicaid requirements may be 
more restrictive that the State practice acts governing PAs. 
The Prospective Payment Review Commission reports that 
23 States require on-site physician supervision of PAs 
under Medicaid even though in 16 of these States PA 
practice acts do not require this supervision. 22 Practitioners 
in Federally-certified rural health clinics must still abide 
by supervision requirements contained in State law or 
regulations. Federal regulations specify that for a clinic to 
be certified under the RHCSA, the physician medical 
director must be at the clinic at least once in every 2-week 
period. State law, however, might require that the 
physician be on-site more often. 14 



30 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Education 

Enrollments in PA programs are burgeoning and the 
number and quality of applicants for these programs is 
greater than ever. In academic year 1992-93, enrollments in 
PA programs was 3,832, up by 424 over the previous year 
and by nearly 1,500 over 1987-88 enrollments. The average 
enrollment per program also increased in academic year 
1992-93 to 35 per class, the largest on record. Similarly, the 
ratio of applicants to enrollees increased to 6.25:1 during 
1992-93, compared to a low of 3.3:1 in 1987-88. 23 

In May 1993, the Accreditation Review Committee on 
Education for the Physician Assistant tallied 61 PA 
programs compared to 55 in 1991, with an additional 15 to 
20 programs in development. 24725 Most of these programs 
are being developed in response to needs for more primary 
care providers in rural and urban underserved areas. 

Currently, PA training programs are stretched to the 
limit regarding qualified faculty. More faculty and 
program directors must be recruited and trained, 
particularly those of minority backgrounds who can serve 
as mentors and role models. 26 Although improvements 
have been achieved in recent years, the attrition rate for 
minorities (17.4 percent) was four times higher than 
majority students (4.9 percent) in 1992. 23 

Finally, physician supervisors should be trained not 
only in the skills of precepting PA students, but also in 
delegating tasks to PAs in practice. A physician's lack of 
knowledge or ability on how to delegate can greatly 
reduce PAs' effectiveness. Knowing how to effectively 
employ PAs may also reduce physician resistance to 
them. 9/27 

Conclusions 

With their broadly-based preparation in primary care, 
shorter and less costly training period, and proven efficacy, 
PAs can be an attractive alternative to physicians. 27 The 
renewed appreciation for PAs as cost-effective and 
qualified primary care providers in the Federal, State and 
private sectors has led to proposals to double their number 
by the year 2000. 25/27/28 



If PAs are to practice at their optimum, however, they 
must work in a supportive environment. Unnecessary 
barriers must be removed, particularly overly restrictive 
State legislation and regulations and complex, inconsistent 
Medicare and Medicaid policies. 

With the prospect of having increasingly larger 
numbers of PAs in the health workforce, it also will be 
necessary to implement a comprehensive faculty 
development initiative. Such an initiative should include 
teaching, research, and leadership development 
components. And, because physicians do not consistently 
understand the role and educational preparation of PAs 
and the scope of their practice, it is essential that they 
receive training in how to best employ these providers. 
One way to do this is to encourage medical schools and 
residency programs to train PAs with medical students, 
and develop programs that will enable physicians to work 
successfully with PAs after graduation. 

References 

1. Office of Technology Assessment. Nurse Practitioners, 

Physician Assistants, and Certified Nurse Midwives: A 
Policy Analysis. Washington, DC: U.S. Congress; 
December 1986. Case Study #37, OTA-HCS-37. 

2. Cawley JF Federal support for physician assistant 

education. Presented at the National Primary Care 
Conference of the Health Resources and Services 
Administration. Washington, DC. March 1992. 

3. Marquardt W. Letter to }. Clowe, President, American 

Medical Association. Alexandria, VA: May 11, 1993. 

4. Hanson C. Access to Rural Health Care: Barriers to Practice 

for Non-Physician Providers. Prepared for the 
Department of Health and Human Services, Health 
Resources and Services Administration. Rockville, 
MD: November 1992. Contract #HRSA-240-0037. 

5. Frye B, Gara N, Reid J. Model State Legislation for 

Physician Assistants. Alexandria, VA: American 
Academy of Physician Assistants; October 1991. 



2993 • Health Personnel in the United States • Ninth Report to Congress • 31 



6. Gara N. Commentary on Model State Legislation for 

Physician Assistants. Alexandria, VA: American 
Academy of Physician Assistants; July 1993. 

7. Gara N. State Regulation of Physician Assistant Practice. 

Alexandria, VA: American Academy of Physician 
Assistants; December 1992. 

8. Office of Technology Assessment, Health Care in Rural 

America: Summary. Washington, DC: U.S. Congress; 
December 1986. OTA-H-435. 

9. Gara N. Barriers from the PA Prospective, Memorandum 

toJ.Emelio,Julyl4,1993. 

10. Physician Assistants Prescribing and Dispensing. 

Alexandria, VA: American Academy of Physician 
Assistants; December 1992. 

11. Profile of the PA Profession - 1993. American Academy of 

Physician Assistants. Twenty-first Annual Conference 
on Physician Assistants. Miami, Florida; June 1993. 

12. Willis J. Barriers to PA Practice in Primary Care and 

Rural Medically Underserved Areas. Journal of the 
American Academy of Physician Assistants. 1993;6:419- 
422. 

13. Office of Technology Assessment. Heath Care in Rural 

America. Washington DC: U.S. Congress; 1990:296-301. 
OTA-H-434. 

14. Gara N. ersonal Communication with Joyce Emelio, 

July 22, 1993. 

15. Frary TN, Reimer LB. The Primary Care Physician 

Assistant in a Rural Office-Based Setting. In: Carter RD, 
Perry, HB, eds. Alternatives in health care delivery: 
Emerging Roles for Physician Assistants. St. Louis; 
Waren H. Green, Inc., 1984:116-27. 

16. U.S. Department of Health and Human Services. 

National Advisory Council of the National Health 
Service Corps. White paper on proposed strategies for 
fulfilling primary care professional needs. Part II Nurse 
practitioners, physician assistants and certified nurse 
midwives. Rockville, MD: U.S. Department of Health 
and Human Services; 1991. 



17. Kole, LA., Removing roadblocks to rural practice. 

Journal of the American Academy of Physician Assistants. 
1993;6:377-379. 

18. Finerfrock W. Resource-based relative value scale. 

Journal of the American Academy of Physician Assistants. 
1992;5:455-458. 

19. Medicare Reimbursement I State Medicaid Programs. 
Alexandria, VA: American Academy of Physician 
Assistants: April 1992. 

20. Physician Payment Review Commission Annual Report 

to Congress 1993: 311-14. Washington, DC. 

21. Third Party Reimbursement for Physician Assistant 

Services. Alexandria, VA: American Academy of 
Physician Assistants; April, 1992. 

22. Medicaid and Midlevel Providers: A Lukewarm 

Relationship?, Intergovernmental Health Policy 
Project. Primary Care News. George Washington 
University. Washington, DC, May 1993. 

23. Oliver DR. Ninth Annual Report on Physician Assistant 

Educational Programs in the United States 1992-1993. 
Alexandria, VA; Association of Physician Assistant 
Programs; June, 1993. 

24. McCarty J. Accreditation Review Committee on 

Education for the Physician Assistant. Letter to 
J. Emelio, dated May 17, 1993. 

25. Bureau of Health Professions. Physician Assistants and 

Health Workforce Development: A Background Paper on 
Physician Assistants, Internal Document. Rockville, MD: 
Department of Health and Human Services; June 
1993. 

26. U.S. Department of Health and Human Services, A 
Model Faculty Development Program for Physician 
Assistants; RFP # HRSA-240-BHPr-34(3)AHL. May 12, 
1993. 

27. Office of Inspector General. Enhancing the Utilization of 
Nonphysician Health Care Providers. Washington, DC: 
U.S. Department of Health and Human Services; May 
1993. Publication OEI-01-90-02070. 

28. Meikle T Josiah Macy, Jr. Foundation Annual Report. 

October 1992. New York, NY. 



32 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Status of Minority and Women Health Care Personnel: 
Availability to Provide Care to Special Populations 



Ernell Spratley, Division of Disadvantaged Assistance, BHPr 



Women historically have comprised the majority of 
personnel in nursing and in many allied health 
occupations. Moreover, for the past two decades, women 
and members of racial and ethnic minorities have made 
significant inroads into health professions once 
overwhelmingly the province of white men. The largest 
gains for most minority groups, however, occurred during 
the mid- to late-1970s. Since that time, with the exception 
of Asians, and, in some professions, Hispanics, minority 
representation in the health fields has been relatively 
stable. 

Women, on the other hand, have continued to 
contribute significantly to the growth in traditionally male- 
dominated health professions throughout the 1980s and 
early 1990s. The majority of the increase in the number of 
first professional degrees awarded in the health 
professions during the 1980s was a result of increases in 
degrees to women. The professions with overall declines 
in the numbers of first professional degrees conferred 
(medicine, dentistry, and optometry), continued to show 
increases in the degrees awarded to women, but were 
insufficient to offset the declines in those awarded to men. 
The substantial gains in the training of women are 
reflected in their increased percentages among the supply 
of health professionals. The number of active women 
physicians, for example, increased more than 91 percent 
between 1980 and 1990, and their percentage among the 
total supply of active physicians increased from 11 to 17 
percent. 1 Table 1 illustrates a similar increase in 
representation for women in other health professions. 

The increase in minority women health professionals 
also was substantial during this period. For example, the 
numbers of first professional degrees awarded to Hispanic 



women in the fields of allopathic, osteopathic and 
veterinary medicine, as well as in dentistry, optometry, 
pharmacy, and podiatry ranged from 118 percent to 600 
percent higher than the numbers awarded in 1981. As 
Table 2 indicates, the number of degrees to women in other 
minority groups increased similarly. Despite the 
seemingly high percentage increases, however, minority 
women still comprise only a very small percentage of the 
graduates from health professions schools and the supply 
of health professionals in this country. Yet available data 
indicate that, overall, the career choices and practice 
patterns of minority women practitioners are more in line 
with national goals than are the career choices of those 
who now dominate the field. For example, in all racial and 
ethnic groups, women are more likely than men to become 
primary care physicians. And among women, the majority 
of young black (60 percent) and Hispanic (57 percent) 
physicians are in primary care while slightly less than half 
(46 percent) of young white and "other" minority women 
physicians are. 3 



Table 1 



Estimated Percent ot Women Practitioners 
in Selected Health Professions: 1980 and 1990 



HEALTH PROFESSIONALS 


1980 


1990 


PHYSICIANS 


11,1 


17.0 


DENTISTS 


3.8 1 


9.5 


PHARMACISTS 


18.3 


28.9 


OPTOMETRISTS 


7.6 2 


14.6 



1 1982 data 2 1984 data 

Sources: American Medical Association; Physician Characteristics and Dislribulionin the U. S. 1992 Edition 
OHHS Health Resourcesand Services Administration; Health Personnel in the United Stales-Eighth Report lo Congress 



1993 • Health Personnel in the United States • Ninth Report to Congress • 33 



For most racial/ethnic 
minority groups, increases in 
the numbers of new health care 
professionals during the 1980s 
reflect increases in the number 
of degrees awarded to men as 
well as to women. However, for 
blacks in medicine and 
dentistry, the gains were solely 
those of black women; the 
number of first professional 
degrees to black men in these 
fields declined during the 
decade. Increasing the numbers 
of underrepresented minority 
health professionals requires 
continued, systematic, and 
substantial gains by both sexes. 
The loss of black male 
professionals in some fields and 
their failure to make the same 
gains as women in others, result in critical setbacks. For 
example, if the number of degrees to black men since 1981 
had increased at the same rate as the number of degrees to 
black women, there would have been 48 more new black 
dentists in 1990 instead of 22 fewer. Medicine presents a 
similar scenario. If the number of medical degrees 
awarded to black men had grown at the same rate as the 
number of degrees to black women, there would have 
been more than 200 more newly trained black physicians 
in 1990, instead of 21 fewer. 

These declines have been attributed to the 
disproportionate participation of black men in a number of 
trends in education, including declining numbers of male 
applicants to health professions schools; the declining 
popularity of undergraduate premedical majors; and, 
declining college participation rates for black Americans; 
and their higher high school drop-out rates. Factors behind 
these trends include a high rate of poverty and lack of 
economic security. 4 





Table 2 

Percent Change in the Numbers of First Professional Degrees 

Conferred to Women by Heaith Field of Study 

and Race/Ethnicity, 1981-1990 






HEALTH PROFESSIONALS 


ALL WOMEN 


WHITE 


BLACK 


HISPANIC AMR. INDIAN 


ASIAN/PACIFIC 






ALLOPATHIC MENICINE 


34.0 


20.1 


42.9 


117.8 


83.3 


313.7 


• 




OSTEOPATHIC MEDICINE 


135.5 


130.6 


-20.0 


600.0 


400.0 


216.7 




DENTISTRY 


60.3 


26.9 


24.6 


464.7 


500.0 


326.7 




PHARMACY 


150.5 


146.7 


108.3 


200.0 


-100.0 


176.9 




OPTOMETRY 


105.8 


99.4 


133.3 


233.3 


-100.0 


142.1 




PODIATRY 


163.8 


133.3 


257.1 


250.0 


0.0 


550.0 




VETERINARY MEDICINE 86.0 83.5 9.5 600.0 300.0 

Source: Complied by Ihe Division ot Disadvantaged Assislance. BHPr based on data 
(torn Ihe National Centet tot Education Statistics as reported in Black Issues in Higher Education, April 9, 1992, pp 36-37 


216.7 



Population Changes and Implications 
for Health Care Needs 

A significant number of the national health goals for the 
Year 2000 involve specific objectives for improving the 
health status of women and children, particularly those in 
low-income and minority groups. Meanwhile, minority 
cohorts of children, women of child-bearing years, and 
elderly women are expected to increase, exacerbating the 
need for culturally and gender-sensitive providers. Table 3 
illustrates the projected increases in population for each of 
these high-demand demographic groups. 

Access to preventive health services, such as 
mammography, breast examination, Pap test, and blood 
pressure monitoring, has improved for many women. 
Significant variations still exist, however, in the use of 
these services among different groups of women. 5 
Changes in the supply of women practitioners (especially 
minority) have important implications for overcoming 
some of the barriers to improving women's health care. 
The likelihood of increasing the acceptability of services 
increases with the supply of minority women practitioners 



34 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Table 3 



Projected Population in Selected Demographic Groups 
by Race/Ethnicity and Percent Change 







L. , I.UUW, U 




PERCENT CHANGE 


POPULATION GROUP 


1992 


2000 


2020 


1992-2000 


1992-2020 


WHITE 




WOMEN 15-44 YRS. 


42,733 


41,008 
37,589 


37,168 
34,646 


-4.0 
-1.1 


-13.0 
-8.8 
36.8 


CHILDREN <15YRS. 


38,000 


WOMEN 65+ YRS. 


16,537 


17,069 


22,616 


3.2 


BLACK 




WOMEN 15-44 YRS. 

CHILDREN <15 YRS. 

WOMEN 65+ YRS. 


7,762 
8,318 


8,146 


9,216 


4.9 


18.7 
29.7 
85.2 


9,120 


10,787 
2,898 


9.6 
10.3 


1,565 


1,726 


HISPANIC 




WOMEN 15-44 YRS. 


5,935 


7,256 


10,586 


22.3 


78.4 


CHILDREN <15 YRS. 


7,146 


8,817 


12,682 
2,550 


23.4 
43.8 


77.5 
233.3 


WOMEN 65+ YRS. 


765 


1,100 


AMERICAN INDIAN 




WOMEN 15-44 YRS. 
CHILDREN <15 YRS. 


456 
562 


484 


602 


6.1 


32.0 


607 


776 


8.0 
26.1 


38.1 
131.9 


WOMEN 65+ YRS. 


69 


87 


160 


ASIAN/PAC. ISLANDER 




WOMEN 15-44 YRS. 
CHILDREN <15 YRS. 


2,126 
1,924 


2,937 


5,002 


38.1 


135.3 
147.1 
386.9 


2,758 
503 


4,755 
1,407 


43.3 
74.0 


WOMEN 65+ YRS. 


289 



(Numbers in Thousands) 

Source: U.S. Bureau of Census. Current Population Reports. Series P25-1092 "Population Projections ol the United Slates by Age. Sex, Race, and Hispanic Origin: 1992 to 2050 " 



and the language and cultural 
compatibility they offer. 

Although both black and 
Hispanic women physicians are 
more likely than others to 
practice primary care, their 
numbers are so small that the 
likelihood of encounters between 
them and the expanding 
population of minority women is 
limited. More than half (62 
percent) of the young primary 
care physicians in the U.S. are 
white men (about 16,000). In 
contrast, there are fewer than 600 
black men, 500 black women, 
1,000 Hispanic men and 300 
Hispanic women young 
physicians practicing primary 
care across the country. Another 
1,600 men and 1,100 women of 
other minority groups also 
practice primary care. 6 

The training of female 
obstetrician / gynecologists, nurse 
practitioners, and nurse 
midwives also is important to 
meeting national objectives 
relating to women's health. The 
number of women OB/GYNs has 
more than doubled since 1980. 
They currently comprise 8 
percent of all active women 
physicians, and 22 percent of all 
OB/GYNs. 7 Black women OB/ 



1993 • Health Personnel in the United States • Ninth Report to Congress • 35 



GYNs are estimated to constitute 11 percent of all black 
women physicians and 25 percent of all black OB /GYNs. 8 
Their representation is even greater among young 
physicians, where they comprise 34 percent of black OB/ 
GYNs. Although women comprise less than one-fourth of 
young Hispanic OB/GYN specialists, among other 
minorities the proportion of women as part of young OB/ 
GYNs rises to about 40 percent. Despite the substantial 
percentages of young minority women physicians 
specializing in OB/GYN, however, less than 3 percent of 
all young OB/GYN specialists are black women and only 
about 1 percent are Hispanic women. 9 

Conclusions 

Overall, enrollment trends suggest that women will 
continue to increase substantially in representation among 
graduates from health professions schools and even more 
of the health care in this country will be provided by 
women practitioners. Kletke and others have projected 
that by the year 2010, 29 percent of the supply of general/ 
family practice practitioners, 32 percent of general 
internists, 46 percent of OB /GYNs, and 54 percent of 
pediatricians will be women. 10 These projected changes, 
along with an anticipated expansion of the role of nurses, 
suggest that women will be providing a significant portion 
of the care to women and children in the future. 

Health professions training data indicate that minority 
women will continue to increase among the supply of 
health care professionals. However, their small numbers 
will limit their availability to the populations who need 
them the most. Minority practitioners as a whole 
(regardless of gender) are unlikely, given the current 
numbers receiving training, to experience increases in 
supply necessary to keep up with projected increases in 
the nation's minority populations. This is not to say the 
provision of health care to minority populations is solely 
the province and responsibility of minority health care 
practitioners. All health care providers will need to 
become more aware of and better able to relate to the 
special needs of this growing segment of the population. 



Despite more than two decades of intervention, the 
declining numbers of black male graduates in some health 
professions, and the continued underrepresentation of 
some other minorities, indicate the need for increased 
efforts in recruitment and retention, with an emphasis on 
black men. Encouragingly, the Association of American 
Medical Colleges (AAMC) has reported a 24 percent gain 
in black male applicants to medical school for the 1993-94 
academic year. 11 Nonetheless, eliminating the substantial 
underrepresentation of all minority health care 
professionals will continue to present significant 
challenges in the coming years. 

References 

1. American Medical Association. Physician Characteristics 

and Distribution in the U.S., 1992 Edition. Chicago. 1992 

2. Young physicians are defines as those under age 40 who 

had been in practice more than one, but fewer than 
seven years after completing residency and /or 
fellowship training. 

3. Decision Demographics. Minority Physicians: A Profile. 

Final Report for Contract No. BHPr-240-92-0041 

4. Ready T, Nickens H. Black men in the medical 

education pipeline: past, present, and future. Academic 
Medicine. April 1991;66:181-187. 

5. The Jacobs Institute of Women's Health. The Women's 

Health Data Book— A Profile of Women's Health in the 
United States. 1991 

6. Decision Demographics. 

7. American Medical Association, 1992 

8. National Medical Association. Unpublished data. 1992. 

9. Decision Demographics. 

10. Kletke P, Marder W, Silberger A. The growing 

proportion of female physicians: implications for U.S. 
physician supply. American journal of Public Health. 
March 1990;80:300-304. 

11. Ready T Minority enrollment reaches new high, but 

continued gains depend on you. Newsletter of the 
National Network for Health Science Partnerships. Spring 
1993;2. 



36 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Health Care and Rural America 

Prepared by Edward S. Sekscenski, Office of Health Professions Analysis and Research, 
and Edwin S. Spirer and Shirley L. Johnson, Office of Program Development, BHPr 



Introduction 

Although rural areas face many of the same health care 
concerns as urban areas, including large numbers of 
uninsured and underinsured persons, rising costs, aging 
populations, and increased prevalence of HIV infection, 
drug abuse, and chronic illnesses, these problems are 
exacerbated in many rural areas by long-standing 
shortages of health personnel and health care providers. 
About one-quarter of the American people live in rural or 
non-metropolitan areas. In 15 States, the proportion is 
more than one-half. 1 While diversity is a major 
characteristic of both rural and urban communities, non- 
metropolitan and metropolitan populations differ in ways 
that are important to health services demand. 

Non-metropolitan areas have greater proportions of 
persons over age 65; higher prevalence of chronic 
conditions such as diabetes, kidney disorders, and 
emphysema; and higher rates of physical impairment than 
do metropolitan areas. 273 Rural family incomes average 
about one-quarter lower than those of urban families, and 
slightly higher proportions of non-metropolitan residents 
under age 65 lack either private or public health 
insurance. 475 Transportation problems are also a major 
concern for many rural residents, especially among the 
elderly, who may not have the ability to travel long 
distances to obtain health care services. 

As noted, however, many rural areas experience greater 
shortages of health personnel than metropolitan areas. 
Seventy percent of all counties designated as Health 
Professions Shortage Areas (HPSAs), which are defined as 
having inadequate levels of primary care physicians, are in 
non-metropolitan areas. 6 In addition, half of all 
underserved persons in the Nation live in rural areas. The 
U.S. Department of Health and Human Services' Bureau of 
Primary Health Care has estimated that about 2,000 
primary care physicians would be needed to remove all 
the Health Professions Shortage Area designations in rural 
areas. 7 



Efforts to address the documented need for enhancing 
health care services delivery in rural areas have been 
developed at the Federal, State and local levels. These 
efforts include the involvement of local community 
leaders, State and regional governments, and regional 
health organizations in rural network formation. These 
organizations help to strengthen rural health 
infrastructures by providing financial incentives to pool 
investment capital, share some costs of services 
production, and conduct utilization review. Some rural 
health providers are also linked with nearby non-rural 
health systems for purposes of providing peer support, 
back-up services, telecommunications capabilities, and 
investment capital, especially for expanding specialized 
services to vulnerable rural populations. 8 Efforts will also 
be necessary to increase the numbers of health 
practitioners who are properly trained and willing to 
practice in rural settings. 

Some rural health care networks organize health 
providers and practitioners in groups financially 
accountable for meeting all the health care needs of their 
service populations, as well as for oversight and utilization 
review of medical care practice in their group. Models of 
such networks have existed in some rural areas for 
decades (e.g. the Marshfield Clinic in Wisconsin and 
Geisinger Medical Center in Pennsylvania). Their wide 
scale establishment, however, would require a great deal 
of modification and adaptation to account for large 
diversities in rural communities. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 37 



Health Personnel Problems of Rural 
America 

Despite increases in rural physician supply over the 
past decade and a half, about half as many physicians per 
capita practice in rural communities as in the United States 
as a whole. 9710 Closures of many rural hospitals, due 
largely to declining occupancy, low reimbursement, and 
high levels of uncompensated care, have reduced 
economic viability for many rural physician practices. 
Other issues including professional isolation, lack of 
continuing and other educational experiences for self and 
family members, slower diffusion of technological 
advances, and below average compensation, have been 
cited as reasons for the unwillingness of physicians to 
begin or remain in rural practice. 11 As a result, an 
estimated 17 million Americans live in rural areas with 
shortages of primary care physicians, nearly 30 percent of 
the total rural population. 

Many rural areas also have shortages of other health 
personnel. The same factors impacting on rural physician 
supply have also been documented as negatively 
influencing the supply of professional nurses. Only 17 
percent of all registered nurses, for example, are employed 
in rural areas. To some extent, however, RNs appear to 
have been supplemented by licensed practical and 
vocational nurses, 32 percent of whom work in rural 
areas. 12 On the other hand, advanced practice nurses, 
especially nurse practitioners, appear to substitute for or 
supplement the small numbers of physicians in some rural 
areas. Nationally, 18 percent of nurse practitioners worked 
in non-metropolitan areas in 1992 as opposed to only 12 
percent of all patient care physicians. 13714 

Physician assistants also are employed in 
disproportionate numbers in rural or non-metropolitan 
areas. Thirty-four percent of all PAs were employed in 
communities of less than 50,000 in 1993. 15 Estimates of the 



proportion of certified nurse-midwives who practiced in 
rural areas, meanwhile, ranged between 11 and 22 
percent. 1 " Barriers to practice for nurse practitioners, 
certified nurse-midwives, and physician assistants, 
however, limit the level of services these practitioners can 
provide in many States. Nurse Practitioners and PAs, for 
example, are denied prescriptive authority in 9 and 16 
States, respectively. Several States also limit 
reimbursement of these practitioners to services provided 
at sites where direct physician supervision is present. 
Such restrictions are potentially detrimental in rural areas 
having shortages of primary care physicians. 17 

Increased practice regulation and professional 
credentialing requirements also impact negatively on 
several allied and associated health occupations, especially 
in rural areas. Some rural health providers state that 
regulations imposed by the Clinical Laboratory 
Improvement Amendments of 1988, which required health 
care personnel to meet greater educational and 
certification requirements, make it more costly for rural 
hospitals and other health care organizations to recruit and 
retain workers. They cite the fact that vacancy rates for 
medical technologists and other clinical laboratory staff in 
rural hospitals are consistently higher than those in non- 
rural hospitals. 18 

Many rural areas also experience shortages of physical 
and occupational therapists, pharmacists, psychiatrists, 
clinical psychologists, social workers, and dentists. 
Analogous to the role played by NPs and PAs are 
psychologists and social workers who appear to provide a 
disproportionate share of the mental health services in 
rural areas, apparently augmenting the dearth of 
practicing rural psychiatrists. 19 Still, the Bureau of Primary 
Health Care estimates that more than 1,000 mental health 
practitioners would be needed to remove all mental health 
HPSA designations in non-metropolitan areas in 1993. 
Meanwhile, 1,000 more dentists also would be needed to 
remove all dental-HPSA designations in non-metropolitan 
counties in 1993. 20 



38 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Strategies for Enhancing Rural Health 
Professions Supply 

Strategies to help build health care capacity and 
increase the supply of health personnel in poorly served 
areas, including rural communities have been 
implemented at the Federal, State, and local community 
levels. In particular, the National Health Service Corps 
and Community and Migrant Health Centers have 
attempted to provide greater health care access for rural 
populations. A study by the Health Resources and 
Services Administration's Office of Rural Health Policy 
found that between 1970 and 1990 nearly 70 percent of 
NHSC practitioners served in rural communities, and that 
their NHSC experiences were significant factors in the 
favorable decisions of former Corps physicians to practice 
in rural areas. 21 

Expansion of programs that encourage increased 
collaboration among health providers and practitioners, 
with emphasis on those in rural areas have also been 
implemented. 22 Examples of such programs include rural 
interdisciplinary training initiatives supported through 
grants by the Bureau of Health Professions. Successful 
team training and delivery of health services have been 
found to alleviate some of the problems associated with 
professional isolation, inadequate back-up, and the lack of 
complementary support for many rural health 
practitioners. 23 

Special rural health personnel training initiatives also 
are sponsored or administrated by the Bureau of Health 
Professions' Division of Medicine. The Rural Health 
Medical Education Demonstration Project, for example, 
administered by the Division and the Health Care 
Financing Administration provides incentives for small, 
rural hospitals to conduct demonstration programs to 
assist physicians in developing clinical experience in rural 



areas. The Division's Area Health Education Centers link 
academic institutions with local planning, educational, and 
clinical resources to provide educational services to 
students, faculty, and practitioners largely in rural areas. 
Additionally, the AIDS Education and Training Centers 
include initiatives for training rural health personnel in 
skills needed to stem the HIV epidemic. 

Several State, regional, and local initiatives also attempt 
to increase the levels of health personnel in specific rural 
areas. 24 Some of these, have been sponsored by national 
organizations such as the W.K. Kellogg and Robert Wood 
Johnson Foundations, and the Pew Charitable Trusts, as 
well as by State and local governments. 

Conclusion 

Several initiatives presently offer opportunities for 
addressing the significant shortages of rural health 
personnel. Individual strategies alone, however, are 
unlikely to solve all of the long-standing health care 
problems of diverse rural communities. Neither expansion 
of coverage nor establishment of rural networks by 
themselves will assure accessibility to suitably trained 
practitioners, or the equitable distribution of appropriate 
health providers to serve all the needs of rural America. A 
coordinated approach is needed to address the particular 
health problems associated with cultural or language 
barriers, homelessness, AIDS, teenage pregnancy and 
childbirth, and mental health that afflict many rural and 
urban communities alike. These and other problems are 
presently exacerbated by the unavailability of health care 
personnel and the lack of an adequate health care 
infrastructure in many rural areas. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 39 



References 

1. U.S. Bureau of the Census. Statistical Abstract of the 
United States: 1993. Washington, DC; U.S. Dept. of 
Commerce, Economics and Statistics Administration; 
1993. 

2. Ibid. 

3. National Center for Health Statistics, "National 
Health Interview Survey," Centers for Disease 
Control, PHS, Hyattsville, MD, 1991, and NCHS, 
"Vital Statistics of the United States," 1992. 

4. U.S. Bureau of the Census. Current Population Reports, 
Money Income of Households and Families in the U.S., 
1992. Washington, DC; U.S. Department of Commerce; 
Series P-60, No 184; September, 1993. 

5. National Center for Health Statistics. Advanced Data 
No. 201: Characteristics of persons with and without health 
insurance, United States, 1989." Rockville, MD; U.S. 
Department of Health and Human Services; 1989. 
Also see, Rowland, Diane, and Lyons. Triple jeopardy: 
rural, poor, and uninsured." Health Services Research. 
February 1989; Vol. 23, No. 6: pp. 975-1004. 

6. Bureau of Primary Health Care. Faxed material 
provided to authors. Rockville MD: U.S. Department 
of Health and Human Services, Public Health Service; 
November 1993. 

7. Office of Rural Health Policy. National Health Service 
Corps Discussion Paper. Rockville, MD: U.S. 
Department of Health and Human Services, Public 
Health Service; February 5, 1990. Also, Bureau of 
Primary Health Care. Faxed material provided to 
authors. Rockville MD: U.S. Department of Health 
and Human Services, Public Health Service; 
November 1993. 



8. Ibid., and Alpha Center, Health Care Reform in Rural 
Areas, A Report of an Invitational Conference; March 
10-12, 1993; Robert Wood Johnson Foundation and the 
Arkansas Dept. of Health, 1993. 

9. Frenzen P. The increasing supply of physicians in U.S. 
urban and rural areas, 1975 to 1988. American Journal of 
Public Health. September 1991; Vol. 81. No. 9. 

10. American Medical Association. Physician 
Characteristics and Distribution in the United States. 
Chicago, IL: 1993. 

See for example, Office of Technology Assessment 
(OTA). Health Care in Rural America: Summary. 
Washington, DC: U.S. Congress. September 1990. 
Publication OTA-H-435. p. 4. 

Ricketts T. Study of Health Professions Distribution, 
Training, and Service Models to Meet Rural Health Care 
Needs, Report of Contract No. 240-89-0037. Rockville, 
MD: U.S. Dept. of Health and Human Services, 
Bureau of Health Professions; 1992. 

Division of Nursing. Sample Survey of Registered 
Nurses, 1992. Rockville, MD: U.S. Dept. of Health and 
Human Services, Bureau of Health Professions; 1993. 

14. AMA,Op.Cit. 

15. Division of Medicine. Special tabulations provided by 
the American Academy of Physician Assistants 1993 
Annual Survey of Membership. Rockville, MD: U.S. 
Department of Health and Human Services, PHS, 
Bureau of Health Professions; October, 1993. 



11 



12 



13 



40 • Health Personnel in the United States • Ninth Report to Congress • 1993 



16. Office of Inspector General, 1990 Survey; and, 
Schupholme A, Dejoseph J, Stobino D, and Paine L. 
Nurse-midwifery care to vulnerable populations, 
phase 1: demographic characteristics of the National 
CNM sample. Journal of Nurse-Midwifery. September/ 
October 1992;37:341-348. 

17. Sekscenski E, Sansom S, Bazell C. and Mullan F. State 
practice environments for physician assistants, nurse 
practitioners, and certified nurse-midwives," In Press, 
1993. 

18. Rickett T, op. cit. 

19. Ibid. 

20. Office of Shortage Designation. Faxed material 
provided to authors. Rockville MD: U.S. Department 
of Health and Human Services, Public Health Service; 
November 1993. 

21. National Advisory Committee on Rural Health. Fifth 
Annual Report on Rural Health. Washington, D.C.: U.S. 
Department of Health and Human Services, Health 
Resources and Services Administration; December 
1992. 



22. Health Resources and Services Administration, 
Interdisciplinary Development of Health Professionals to 
Maximize Health Provider Resources in Rural Areas 
Report of Contract No. HRSA 240-89-0037. Rockville, 
MD: U.S. Department of Health and Human Services, 
Bureau of Health Professions, Office of Program 
Development; March 1993. 

23. American Hospital Association. Increasing Rural Health 
Personnel, Community-Based Strategies for Recruitment 
and Retention. Hospital Research and Education Trust. 
Chicago, IL; 1992. 

24. American Hospital Association. Increasing Rural Health 
Personnel, Community-Based Strategies for Recruitment 
and Retention. Hospital Research and Education Trust. 
Chicago, IL; 1992.1 



1993 • Health Personnel in the United States • Ninth Report to Congress • 41 



4.2 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Preparing a Nurse Workforce Appropriate 
for Current and Future Health Care Delivery 

Madeleine R. Hess, Ph.D., R.N., C.S.; Division of Nursing, BHPr 



Introduction 

Key to an adequately prepared nurse workforce is 
nursing education. Nursing and the nursing educational 
system face the challenge of filling spiraling demands for 
baccalaureate level trained nurses and master's prepared 
advanced practice nurses for nonhospital settings. The 
focus on these levels of preparation in nursing is a 
response to trends in the health care delivery system, in 
society and in the nursing education system itself. 
Consider these facts. Although there are fewer managed 
care systems now than in the 1980' s, they are larger, with 
some counting memberships of more than 1 million. 1 
Home care respiratory and dialysis technology is expected 
to grow annually by 15 and 30 percent respectively. 2 
These and other indicators point to the need for nurses in 
community settings. In addition, hospital utilization of the 
largest share of the total professional nurse supply is 
expected to dominate demand into the 21st century. 
Although in-patient stays have decreased by more than 50 
percent in the past 20 years, increases in the acuity of 
patients in these high-technology settings have caused 
corresponding increases in the complexity of nursing 
functions. The base of professional and advanced nursing 
preparations offer strengths upon which to build dynamic, 
innovative and responsive programs to meet the 
challenges of health care into the twenty-first century. 

Trends in the Student Population 

Composition of the Student Body 

In October 1991, 30 percent of the students enrolled in 
baccalaureate nursing education programs were RNs 
returning for a first baccalaureate degree. 3 Meanwhile, the 
increasing number of nontraditional, non-nursing, 
baccalaureate-prepared, second-career students entering 
nursing is striking. This trend has been credited with the 
development of 5 new generic master's programs and 16 
new baccalaureate programs. 4 An encouraging aspect of 
the presence of these nontraditional and post-RN students 
in these programs is that nurses and non-nurses alike are 
recognizing the importance and marketability of the 
baccalaureate. It may be that innovative programming 



offered by new and existing programs better meets the 
needs of both types of students than did full-time, 
traditional programs. The promise of these somewhat 
older nurses is dimmed slightly by the observation in the 
Eighth Report that by 2020, more than half of the nursing 
workforce will be 50 or older. The need to attract the best 
and brightest of our youth into a career in nursing remains 
a continuing challenge. 

Ethnic and Culturally Diverse Students 

Currently, about 16 percent of enrolled students who 
are preparing to become registered nurses come from 
racial and ethnic minority backgrounds. A higher 
percentage (17.6 percent) of the baccalaureate program 
students were from racially and ethnically diverse 
backgrounds, including about 10 percent of whom are 
black. Although these data indicate improvement over 
earlier years, minority enrollments could be strengthened 
further through greater recruitment and retainment efforts. 

Basic Nursing Preparation 

Entry into nursing primarily continues along three 
pathways: hospital based diploma programs; associate 
degree programs, mostly based in community colleges; 
and college or university based programs leading to a 
baccalaureate. During the academic year 1991-1992, 
almost two-thirds of all new graduates of nursing (65 
percent) earned associate degrees; a marked increase over 
10 years earlier when about half the total graduates came 
from these programs. The percent of graduates from 
baccalaureate programs, meanwhile, has remained about 
the same. The irony of this trend is that future demand is 
oriented toward the baccalaureate-prepared nurse. 
Community nursing and care provided in ambulatory 
settings require the broad-based education most 
commonly found in baccalaureate programs. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 43 



It is important to address the educational programs in 
the context of the needs of the health care delivery 
system. 5/6/7/8 Associate degree program content 
emphasizes clinical practice within the hospital setting, 
while the baccalaureate program contains proportionately 
more preparation for practice in nonhospital settings. 
As Rosenfeld points out, the public health content of the 
associate degree curriculum, on average, is less than 40 
hours, or 2 percent of the total, compared with the 
baccalaureate content of 173 hours or 16.5 percent. Clinical 
practice time in ambulatory care and other community 
settings in the baccalaureate curriculum averages twice 
that of the associate degree curriculum. 9 Nurses with 
nonhospital training are apt to be better prepared for the 
administrative, consultative and primary care (physical 
examination, psychosocial assessment and nursing 
diagnosis) responsibilities they will assume in community 
and ambulatory settings. 10 

Of concern to both types of degree programs is the 
apparent lack of correspondence between clinical skills 
taught and expectations of new graduates. One study of 
131 programs reported that, of 54 skills identified, new 
associate degree and baccalaureate graduates had 
experience in fewer than 12." The broader, more scientific, 
curriculum at the baccalaureate level, however, offered 
nurses more tools for systematic problem-solving and 
autonomous practice in the community. Nonetheless, 
there appears to be a need for additional practice to master 
high-technology skills. The implications for basic nursing 
education may be the development of strong partnerships 
with practice institutions to meet the high technology 
demands of all settings with qualified graduates. 



Graduate Nursing Education 

The trend toward both the "curing and caring" roles for 
nursing argues for the movement toward advanced 
practice preparation. 12 Advanced practice nursing 
encompasses the work of clinical nurse specialists, nurse 
practitioners, nurse-midwives, and nurse anesthetists. 
The last three categories are the most visible to the public. 
These advanced practice nurses have in common 
autonomous practices and direct patient care responsibility 
in a variety of nonhospital and hospital settings. Demand 
for advanced practice nurses is expected to climb 
dramatically in the next century due to the predicted 
trends in the population and the anticipated changes in the 
health care delivery system. Ongoing State and private 
sector changes to the health care delivery system will 
increase the need for primary health care providers. 
Increase in demand is especially predicted for nurse 
practitioners and nurse-midwives who already provide 
prevention, primary care, diagnosis, treatment, 
rehabilitation and gatekeeper services in a variety of 
settings serving a diversity of people. In a few settings, an 
emerging trend is the utilization of nurse practitioners to 
replace house staff physicians in hospitals. 13 Increased 
complexity in hospital care may also add to the growth in 
the demand for advanced practice nurses. 

Despite the fact that the faculty vacancy rate has not 
changed for several years, additional faculty with 
advanced practice nursing expertise will be required. 
This demand for faculty is of concern because graduate 
students in nonclinical tracks are twice as likely to be 
enrolled in nursing administration rather than in nursing 
education. 14 The role and reward system of clinical faculty 
may need to be examined in light of the evolving health 
care delivery system and its demands. Academic reward 
systems may need to recognize the faculty's clinical 
practice as a legitimate activity, with status equal to that 
accorded to research activities. 



M • Health Personnel in the United States • Ninth Report to Congress • 1993 



Advanced Practice Nursing and Special Conclusion 
Populations 



Many special populations who might benefit from the 
skills of advanced practice nurses are increasing in size. 
Both the very young and the very old chronically ill are 
living longer. The 31.1 million uninsured, 25 percent of 
whom live below the Federal poverty level, pose even 
greater demand for primary care, prevention, diagnostic, 
treatment, rehabilitation and case management activities. 
The increasing numbers of alcohol and other drug users, 
those infected with HIV, noninstitutionalized mentally ill, 
and the homeless have taxed the public health care system 
beyond its capacity to respond effectively. Access to health 
care remains a continuing problem for the inner-city poor 
and rural underserved, many of whom are minorities. 
The value of prevention, intervention, and the monitoring 
of people with multiple risk factors for disease is cost- 
effective, and it is well documented in the literature that 
both nurse practitioners and nurse midwives have 
provided quality, affordable and accessible ca re. 15/16/17/18/19/ 

20/21/22 

Effective delivery of health care services to special 
populations points to the need to develop nursing 
programs with interdisciplinary components specific to 
the provision of treatment and promotion of wellness in 
chronic patient populations, especially the aged and 
children. In addition, the information explosion will 
require expertise in information management; the 
dilemmas stimulated by increasingly sophisticated 
technology will require strengths in bioethics; and the 
needs of the underserved will require strong clinical skills, 
patient advocacy activities, and the ability to influence 
health care policy. 



To continue to ease the burden of access to health care 
services, a pool of baccalaureate-educated nurses must be 
available. A growing body of literature supports the need 
for baccalaureate education for effective service delivery in 
non-hospital settings, and a prerequisite for advanced 
practice preparation. Innovative, high-technology 
programs can provide increased access to non- 
baccalaureate prepared registered nurses to obtain the 
degree and help ease the current shortage of baccalaureate 
prepared nurses. 

At the master's level, highly skilled, multidisciplinarily 
educated advanced practice nurses in all specialties 
working within a variety of practice models are slowly but 
effectively reducing the need for primary health care 
providers. The task will be to increase the numbers of 
advanced practice nurses in an already economically 
burdened educational system. 

These conclusions are reinforced by major national 
reports, including that of The Pew Health Professions 
Commission and the W. K. Kellogg Foundation's National 
Commission on Nursing Implementation Project. The 
challenge will be to find new and better ways to provide 
nurses with training adequate to meet the health care 
needs of the future. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 45 



References 

1. Vogel DE. Family Physicians and Managed Care: A View to 

the 90s. American Academy of Family Physicians, 
1993. 

2. Maraldo P. Ten trends to watch. Nursing and Health Care. 

January 1986;7(1):17-19. 

3. National League for Nursing. Nursing Data Source 1992 

Volume I, Trends in Contemporary Nursing Education. 
New York, NY; 1992. Publication No. 19-2480. 

4. American Association of Colleges of Nursing. Nursing 

School Enrollments See Continued Growth: AACN 
Report Shows. December 1992. 

5. O'Neil EH. Health Professions Education for the Future: 

Schools in Service to the Nation. San Francisco, CA: Pew 
Health Professions Commission; 1993. 

6. Hegyvary ST. Haussman RKD. Correlates of the quality 

of nursing care. Journal of Nursing Administration. 
1976;6:22-27. 

7. Hughes KK, Young WB. The relationship between task 

complexity and decision-making consistency. Research 
in Nursing and Health. 1990;13:189-196. 

8. Young WB. Who sets nursing standards: the nursing 

profession or the employment setting? Nursing 
Administration Quarterly. 1988;12(2):78-86. 

9. Rosenfeld P, Kaufman K. Adequacy of clinical 

preparation among new graduates: an investigation 
of the relationship between the perceptions and 
realities of clinical preparation in basic nursing 
education. Proceedings and Abstracts: Eighth Annual 
Conference on Research in Nursing Education. National 
League for Nursing, 1990. 

10. Hughes KK, Marcantonio R. Practice patterns among 

home health, public health and hospital nurses. 
Nursing and Health Care. December 1992;13(10):532- 
536. 

11. Neighbors M, Eldred E. Technology and nursing 

education. Nursing and Health Care. 1993;14(2):96-99. 



12. Bullough B. Alternative models for specialty nursing 

practice. Nursing & Health Care. May 1992;13(5):254- 
259. 

13. News Release. ANA calls for more use of nurse 

practitioners in hospitals. American Nurses 
Association; December 16, 1992. 

14. National League for Nursing. Nursing Data Source 1992, 

Volume III, leaders in the Making: Graduate Education in 
Nursing. New York, NY; 1992. Publication No. 19-2482. 

15. Safriet BJ. Health care dollars and regulatory sense: the 

role of advanced practice nursing. Yale journal on 
Regulation. 1992;129-220. 

16. Igoe J, Gordano B. Expanding School Health Services to 

Serve Families in the 21st Century. Washington, DC: 
American Nurse Publishing; 1992. 

17. Barger S. Rosenfeld P. Models in community health 

care: findings from a national study of community 
nursing centers. Paper Presented at the Third Primary 
Care Conference; January 10-12. 1993; Atlanta, GA. 

18. Metropolitan Council Report. Living at Home and Block 

Nurse Programs: An Analysis of Client and Cost 
Information. St. Paul, MN; 1990. Publication No. 420- 
91-019. 

19. Scupholme A, Dejoseph J, Strobino DM, Paine LL. 

Nurse midwifery care to vulnerable populations- 
Phase I: demographic characteristics of the national 
CNM sample, journal of Nurse-Midwifery. September- 
October;^ 37(5):341-348. 

20. Coslow F The nurse practitioner in the HMO. HMO 

Practice. 1992;6(3):25-28. 

21. Gesensway D. Despite medicine's protests, NPs and 

PAs winning turf as primary care practitioners. ACP 
Observer. December 1, 1992. 

22. DeBack V, Nursing education. Nursing's Vital Signs: 

Shaping the Profession for the 1990s. W K. Kellogg 
Foundation, MI; 1990. 



46 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Health Care Services for Persons with HIV/AIDS 

by Edward S. Sekscenski, MPH; Office of Health Professions Analysis and Research, BHPr. 



The human immunodeficiency virus (HIV) epidemic 
has affected every segment of our health care system. 
Treatment for those infected, health education, testing, 
monitoring, and prophylaxis all have required increasing 
resources over the past dozen years. Still, more services 
are needed than are being provided. A recent study 
estimated that as few as a third of those infected are 
receiving health services for their infections on a regular 
basis. Even among those with symptoms, only an 
estimated half received non-home health services regularly 

Estimates of HIV and AIDS in the U.S. 
Population 

The Centers for Disease Control and Prevention (CDC) 
estimates that between 800,000 and 1.2 million in the 
United States are infected with HIV, and that some 40,000 
persons are likely to become infected each year throughout 
the 1990's. 2 In January 1993, the CDC revised its 
HIV-classification system and case definition for AIDS. 
Consistent with the revised classifications, the new AIDS 
definition includes all HIV-infected persons with CD4 
counts below 200, and expands the list of 23 clinical 
conditions in AIDS surveillance by three-pulmonary 
tuberculosis (TB), recurrent pneumonia, and invasive 
cervical cancer. The expanded definition is expected to 
have a substantial impact on the number of reported AIDS 
cases, especially increasing the number of women 
diagnosed. Meanwhile, the CDC estimates that 100,000 are 
co-infected with HIV and tuberculosis (TB), and face a 
substantially increased risk of developing active TB. 3 

Current and Projected Numbers of 
Persons in Treatment for HIV 

In a study conducted for the Bureau of Health 
Professions by the New York State Department of Health, 
the number of persons receiving HIV services on a regular 
basis in hospitals, primary care centers, and nursing 
homes was estimated at 311,000 in 1990-91. l Although 
infected persons also receive informal and support 
services, home health, and specialized health care, national 
estimates of such services are not available. Some persons 



only begin regular treatment for HIV after their CD4 
counts fall below 200, the level that qualifies as a full- 
blown AIDS diagnosis. Lack of access, especially to 
primary health care, among poor urban and rural 
segments of the population poses serious challenges. 
Historically, these groups have had the least access to 
health care services, yet they are currently the most 
vulnerable to new HIV infection. The fact that many 
programs providing HIV services are operating at or near 
capacity further limits access. 

Efforts to ameliorate this problem have been 
implemented at the State, local, and National levels. One 
initiative, administered by the Health Resources and 
Services Administration (HRSA) through the Ryan White 
C.A.R.E. Act, supports expansion and development of 
community-based health and support services for low 
income persons with HIV in 25 metropolitan areas. 4 Other 
initiatives include dissemination of guidelines for 
increasing HIV testing in hospitals, strategies for 
increasing HPV services in substance abuse programs, and 
support for HIV health education. 57677 Also, HRSA's 
Bureau of Health Professions sponsors 17 AIDS Regional 
Education and Training Centers (AIDS-ETCs) for training 
health professionals in HIV counseling, prevention, and 
treatment. 879 

Based on current trends in utilization of hospitals, 
primary care centers, and nursing homes, New York State 
projects that nationally, more than 140,000 persons will 
enter regular HIV treatment annually in the 1990s. 
Because as many as two-thirds of those estimated to be 
infected may not be receiving regular care, and increased 
funding for HIV services will likely expand access, the 
actual number of persons in HIV treatment in the future 
will likely exceed this estimate. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 47 



HIV Treatment in Selected Segments 
of the Health Industry 

Although some HIV-positive persons remain 
asymptomatic for years, all infected persons require 
increased health services, ranging from counseling to 
serological monitoring and therapeutic treatment. The 
epidemic also requires that increased levels of services be 
provided to those at high risk of infection and the general 
public. Because of the multiplicity of services needed and 
because treatment strategies are changing rapidly, no one 
model works best. Estimates of HIV services provided 
vary dramatically by region of the country due to basic 
differences in regional health care systems, 
epidemiological differences in the spread of HIV, and 
differences in reimbursement. 

Primary Care Services Provided to 
HIV/AIDS Patients 

The vast majority of patients in regular treatment for 
HIV receive primary care services in physicians' offices, 
hospital-based or free-standing clinics, health centers, and 
hospital outpatient and emergency departments. 
Nationally, 303,000 persons were estimated to be active 
patients in primary care HlV-treatment in 1990-91, based 
on the New York State study. Types and volume of 
primary care HIV services vary dramatically by patient 
and provider characteristics. 

The New York State study, for instance, divided HIV 
patients into four groups. Of the approximately one 
million HIV-infected persons in the United States, 41 
percent were estimated to be asymptomatic (CD4 counts 
above 500), 39 percent early symptomatic (between 
200-499), 12 percent symptomatic (between 50-199), and 8 
percent late symptomatic (below 50). Fewer than a fifth of 
the asymptomatic were believed to be in regular treatment 
for HIV, while a quarter of those with early symptoms and 
half with symptoms were receiving such care. Given the 
severity of their illnesses, a surprising one in nine late- 
symptomatic persons were believed to be not receiving 
regular treatment in 1991 (see Table 4). 



Table 4 



Estimated Numbers of HIV-infected Persons in the U.S. 

and Numbers Estimated to be Receiving Regular 

Primary Care Services, According to the Severity 

of Their Illnesses, 1992 





CD4 CELL 
COUNT 


TOTAL 
PERSONS 


TOTAL IN 
TREATMENT 


PERCENT IN 
TREATMENT 






ASYMP: >500 


411,000 


70,00 


17.0% 






EARLY SYM: 200-499 


394,000 


107,000 


27.2% 




SYMPTOM: 50-199 


120,000 


59,000 


49.2% 




LATE SYM: <50 


75,000 


67,000 


89.3% 




TOTALS: 1,000,000 303,000 

Source: New York State Department of Health 


30.3% 



Full-time-equivalent (FTE) staff-to-patient ratios and 
substitution of health personnel differed by personnel 
category and the intensity of services provided. Staff-to- 
patient ratios of physicians and nurses differed by factors 
of about one-and-a-half between high and low volume 
care levels. HIV care in higher volume settings is more 
likely to be provided by physician assistants, nurse 
practitioners, and social workers than in lower volume 
settings (see Table 5). 

Estimates of HIV/ AIDS Care in 
Hospitals 

Although most HIV illnesses are manageable through 
outpatient care with regular provision of therapeutic 
agents, inpatient hospital services remain critical for 
persons with acute illnesses. Of the estimated 311,000 
persons receiving HIV care on a regular basis in 1991, 
about 7,000 were hospitalized on any given day. These 
persons used an estimated total of 2.6 million inpatient 
days nationwide in 1990-91, according to the New York 



48 • Health Personnel in the United States • Ninth Report to Congress • 1993 





Table 5 

Estimated FTE Health Personnel Providing 

Primary Care to Patients in High and Low 

Volume HIV Care Settings, 1991 






HIGH INTENSITY LOW INTENSITY 






PHYSICIANS 1:286 1:404 






PAsorPNs 1:311 1:2,084 






NURSES 1:303 1:537 






SOCIAL WORKERS 1:557 1:2,589 






FTE Staff/Patient Ratios 





State study. It confirmed what other studies have shown 
— that HIV hospital use varies widely by state. 10 For 
example, although New York and California each 
accounted for a fifth of national AIDS cases in 1990, New 
York had a third of all HIV hospital days while California 
accounted for only one-ninth. 

Clinical and demographic differences in States' 
HIV-infected populations undoubtedly affect their hospital 
use rates. Historically, however, Western States, especially 
California, have responded to the epidemic with fewer 
hospitalizations and more ambulatory care services than 
have Eastern States, especially New York. In a 1988 
national study of public hospitals, for example, the 
average annual number of total hospital days per HIV 
patient in the Northeast was twice that of the West, 40.4 vs. 
19.3 days. 11 Intensity of services also varied. An average 94 
percent of HIV inpatient days in the Northeast were 
classified as acute care levels compared to 78 percent in 
Western States. 

Resource use also varies within states. In a two-year 
study of 40 Massachusetts hospitals, for example, 86 
percent of AIDS hospitalizations occurred in 20 percent of 
the hospitals. Hospitals with fewer AIDS discharges used 
more resources per AIDS patient, measured by admissions 
to intensive care units, lengths of stay, and cost, than did 
hospitals with higher proportions of AIDS patients. After 



controlling for case severity, however, AIDS mortality was 
substantially lower in hospitals with greater proportions of 
AIDS patients. 12 

The health care personnel used in providing HIV 
services vary by hospital type and size, geographic region, 
availability of specific personnel, existence of a dedicated 
AIDS unit, and the extent to which dedicated units share 
staff with other hospital departments. 13 Several studies 
suggest that AIDS-unit patients receive greater levels of 
care than those in general units. One study found 
registered-nurse-to-bed ratios in 21 AIDS units to be 50 
percent greater than in non-AIDS units of the same 
hospital. 14 In another study, AIDS-unit patients received 
more hours of nursing care per day than AIDS patients in 
general units; the latter received the same level of care as 
non-AIDS patients. 15 Most AIDS patients, however, are not 
treated in AIDS-specific units. 

Hospital staffing also varies widely among AIDS- 
specific units. In a sample of 20 dedicated and 4 integrated 
units in 12 states, FTE registered-nurses-to-patient ratios 
varied by a factor of four. Ratios of other personnel varied 
more. One reason for these differences is the fact that 
many AIDS units share staff with other hospital 
departments, especially for provision of respiratory and 
physical therapy, laboratory, and social services. 
Reimbursement also impacts on staffing levels. 

Nursing Home Care for HIV/ AIDS 
Patients 

Nursing homes are used by a small number of persons 
in late stages of HIV illnesses. AIDS nursing home 
patients, particularly in hospital-based skilled nursing 
homes, require and receive more hours of nursing services 
per day than non-AIDS patients. Much AIDS nursing 
home care appears to be in dedicated AIDS units. The 
National Commission on AIDS reports that most nursing 
homes may not be well-equipped to meet the needs of 
persons with HIV because, unlike many elderly patients, 
most HIV-infected persons alternate between periods of 



2993 • Health Personnel in the United States • Ninth Report to Congress • 49 



illness and relative wellbeing. Although the Commission 
believes nursing homes must become more capable and 
willing to provide HIV services, especially as alternatives 
to hospital care, better access to home health and primary 
care HIV services should also be encouraged. 16 

The New York State study estimated a national average 
daily census of 1,400 AIDS patients in nursing homes in 
1992, based on limited information from six States that 
collectively accounted for about two-thirds of AIDS case 
prevalence at the time. Nursing home use in those six 
States ranged from 8 to 56 patients per 1,000 AIDS cases, or 
an average utilization rate of 22 per 1,000 cases. Nursing 
home use in other states was assumed to approximate this 
average. 

Although AIDS patients require more personnel than 
non-AIDS patients in nursing homes, nursing homes 
appear to provide a less costly alternative to some 
hospitalizations. As with hospitals, staffing of AIDS 
nursing home care varies widely (see table 6). FTE ratios 
for nurses, for example, ranged from .14 to .48 per AIDS 
nursing home patient, far below those in most hospitals. 

Home Health, Hospice, and Alternative 
HIV Services 

Home health care is integral to the continuum of care 
for HIV patients. HIV home health services have grown in 
volume and become more specialized in the dozen years of 
the epidemic. Models of HIV home care vary by agency 
type and geographic area. Services include patient 
assessment, skilled nursing care (such as infusions and 
aerosolized pentamidine treatments), personal care 
services, mental health /counseling, and case management. 
Most agencies reporting funding sources for these services 
include both Medicaid and private sources of payment. 

Home health agencies are staffed largely with nurses 
(generally registered nurses), therapists, social workers, 
and aides. Few have physicians on staff, but they may 
have referral relationships with specific medical providers. 
Use of staff varies dramatically among agencies that 



Table 6 



FTE Staff to Patient Ratios in Nursing Homes 

Providing HIV/AIDS Care According to 

Category of Health Personnel, 1992 







AVERAGE 


RANGE 






NURSES 


0.29 


0.14-0.48 






THERAPISTS 


0.03 


0.02-0.07 






SOCIAL WORKERS 


0.06 


0.02-0.15 






AIDES & ASSISTANTS 


0.41 


0.13-0.58 






Staff/Patient Ratios 







provide HIV care. In a study of 17 agencies in 11 states, 
the average length of time services were provided to 
patients ranged from 4 to 104 weeks, and nurse visit 
frequencies ranged from one to six a week per HIV patient. 
Among those providing social work services, the average 
numbers of visits ranged from .1 to .5 a week per patient. 
Visits lengths and service intensities varied dramatically 
among health occupations and agency types. 

Most home health agencies that provide HIV services 
both receive referrals from and assist in coordination of 
community care for HIV patients. According to a study 
conducted for HRSA's Bureau of Health Resources 
Development, professional nurses often fill the role of case 
manager. 17 Social workers, physicians, and others, 
however, also provide this function. Some home health 
agencies work in conjunction with other providers to offer 
adult day care, respite care, and personal care services in 
outpatient settings. HIV home health care is also being 
developed by long-term care hospitals, often on a 
contractual basis with Visiting Nurse Associations. 



50 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Hospices, both in-home and institutional models, 
provide services to patients in the end-stages of AIDS- 
related illnesses. Many HIV patients are unwilling to 
embrace the hospice concept of reduced medical 
treatment, however, due to the unpredictability of HIV 
illnesses. In some cases newer "high-tech" AIDS hospices 
have been developed that continue aggressive therapy. 
Many of these are still experimental in nature. 

Health Personnel Providing Services 
for the HIV Epidemic 

Virtually all types of health professionals address the 
many aspects of the epidemic. Beyond providing care to 
HIV patients, health personnel conduct HIV /AIDS 
research, develop and implement health education 
programs, develop and evaluate treatment protocols, and 
provide HIV counseling to the general public. 

Nursing services are the dominant care provided to 
HIV patients. Nurses function as educators, counselors, 
discharge planners, and case managers for HIV patients, 
and treat persons at high risk for HIV-infection in sexually 
transmitted disease clinics, substance abuse programs, and 
public health centers. All nurses, therefore, need HIV 
education and training along with information on 
safeguards that should be taken in providing care to 
persons whose HIV-status is unknown. Research to 
improve nursing service effectiveness and efficiency in 
treating HIV also is needed. 

An estimated 15 million physician visits occur annually 
for HIV counseling, testing, treatment and related 
services. 18 Specialty HIV care encompasses virtually all 
physician services. 

Dental personnel are often the first health professionals 
to note HIV-related infections. In a 1990 National Institute 
on Dental Research survey, however, only 60 percent of 
dentists expressed a willingness to treat HIV patients. 19 
Training programs are needed to enhance the capabilities 
and the willingness of dental personnel to detect and treat 
HIV-related infections and make appropriate referrals for 
medical care. Training should emphasize infection control 
for all patient encounters. 



Allied health personnel play a major role in providing 
HIV care, especially in hospitals and home health agencies. 
Physical and occupational therapists help to maintain as 
much independence as possible for HIV patients. 
Dietitians and nutritionists are essential in sustaining 
patients' physical conditions. Respiratory therapists 
administer aerosolized treatments for TB and 
Pneumocystis carini pneumonia. Other allied health 
personnel directly involved in HIV treatment and care 
include speech-language and hearing pathologists, 
medical technologists, clinical laboratory personnel, and 
emergency medical, radiologic service, and medical 
records technicians. 

Psychiatrists, clinical psychologists, clinical social 
workers, and psychiatric nurses, provide counseling, 
support services, treatment, and health education for 
persons with HIV, their friends and families, and the 
general public. Mental health practitioners involved with 
substance abuse treatment and counseling programs, and 
those who work in sexually transmitted disease clinics, 
community mental health centers, and community health 
clinics are in the forefront of efforts to stem the spread of 
HIV. There is a special need for increased HIV education 
among providers responsible for reaching out to segments 
of the population at risk of exposure to HIV. 

Health educators, biostatisticians, epidemiologists, and 
occupational health and safety personnel, and other public 
health personnel are involved in many aspects of HIV care. 
Health education and promotion programs are the most 
effective measures in preventing the spread of the 
epidemic. Increasingly, responsibility for treatment, 
research, and administration of HIV care is falling to 
public health agencies. Those employed in public health 
agencies need to be more fully prepared to provide 
effective services and relevant education to health 
professionals and the public regarding the HIV/AIDS 
epidemic. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 51 



References 

1. Gordon, Daniel, and Epple. Estimating Health Personnel 

Supply Providing HIV Services. New Your State 
Department of Health, 1993. 

2. Center For Disease Control and Prevention. Projections 

of the number of persons diagonsed with AIDS and 
the number of immunosuppressed HIV-infected 
Persons in the U.S., 1992-1994. Atlanta GA: Center for 
Disease Control and Prevention; December 25, 1992. 
MMWR. Vol. 41 No. RR-18 

3. The CDC estimated that there were 39,000 more cases of 

TB reported between 1985 and 1991 than would have 
occurred had the incidence of TB continued declining 
at the rate it was prior to 1985. Special Report, 
Tuberculosis: an old disease poses new challenges to 
public health policy and the law. Supplement to AIDS 
Policy and the Law. April, 1993. 

4. HRSA Notes, March 1993. 

5. CDC. Recommendations for HIV testing services for 

inpatients and outpatients in acute care hospital 
settings and technical guidance on HIV counseling. 
MMWR. 1993;42(No. RR-2):1-17. 

6. See U.S. DHHS. Training Drug Treatment Staff in the Age of 

AIDS: A Frontline Perspective. ADAMHA, NIDA, 
Clinical Report Series, 1991. 

7. See Noble GR. How the response to the epidemic of HIV 

infectioon has strengthened the Public Health Service. 
Public Health Reports. 1991;Nov.-Dec.:608-615. 

8. U.S. Public Health Service. Strategic Plan to Combat HTV 

and AIDS in the United States. Washington, DC: U.S. 
Department of Health and Human Services; 
November, 1992. 

9. Health Resources and Services Administration. HRSA 

AIDS Activities. Washington, DC: U.S. Department of 
Health and Human Services; 1992. 

10. AHCPR, Ball JK, Turner B. Aids in U.S. Hospitals, 1986- 

87: A National Perspective. Washington, DC: U.S. 
Department of Health and Human Services; Hospital 
Studies Program Research Note 15, 1991. Publication 
No. 91-0015. 



11. National Association of Public Hospitals. AIDS Care. 19. 

12. Stone VE, Seage III GR, Hertz T, Epstein A. The relation 

between Hospital experience and mortality for 
patients with AIDS. JAMA. 1992;Nov. 18:2655-2661. 

13. Virtually all hospitals in the U.S. treated HIV/AIDS 

patients in 1990-91. Due to the availability and 
substitution of health personnel, staff to patient ratios 
vary widely. American Hospital Association data for 
1990 show staff to patient ratios for RNs in all U.S. 
hospitals, for example, ranged from a low of about 0.9 
in five States to an about 1.5 in five other States. 
Assumably, health personnel requirements for treating 
HIV /AIDS patients are also greater in hospitals wtih 
higher staff to patient ratios. 

14. Lake E. Written Communication from research study, 

Aids Care: Nurse Retention and Patient Satisfaction. 
University of Pennsylvania, Center for Health 
Services Policy Research. 1991. 

15. Van Servallen G, Lewis CE, Schweitzer SO, Leake B. 

Quality and cost of AIDS nursing care as a function of 
inpatient delivery systems. Journal of Nursing 
Administration. 1991;21(9):21-28. 

16. Report of the National Commission on Acquired 

Immunodeficiency Syndrome. America Living with 
AIDS. 1991;53. 

17. John Snow, Inc. Home Care Services for Persons with HIV 

Illness, Analytical Synopsis (Final Draft). U.S. 
Department of Health and Human Services; 
1993:January 14. Contract No. HRSA 240-90-0060. 

18. Bureau of Health Professions. Seventh Report to the 

President and Congress on the Status of Health 
Personnel in the United States. Washington, DC: U.S. 
Department of Health and Human Services; March 
1990. DHHS Publication No. HRS-P-OD-90-1. 

19. Sadowsky D, Kunsel C. Are you willing to treat aids 

patients?. Journal of the American Dental Association. 
1991. 



52 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Physicians 



Sandy Gamliel, Office of Health Professions Analysis and Research, BHPr. 



Approximately 597,400 active allopathic physicians 
were practicing in the United States in 1992. Of these, 
441,624, or 74 percent, provided patient care. However, 
only 33 percent of these patient care physicians were 
primary care physicians, as defined by the Bureau of 
Health Professions as family and general medicine, 
general internal medicine, and general pediatrics (see the 
section on primary care for a more detailed definition). In 
addition to allopathic physicians, some 32,489 osteopathic 
physicians were active in 1993, 46 percent of whom were 
primary care practitioners. 

Increases in the number of physicians over the last 
decade have outpaced population growth. In 1992, the 
allopathic physician-to-population ratio reached an all- 
time high of 255 per 100,000, 26 percent higher than in 
1980. This ratio is expected to continue increasing into the 
next century as the supply of physicians grows faster than 
the population. The increase in physician supply results 
from growth in both the number of graduates of U.S. 



Figure 5 

Supply of Activie Physicians (MD & DO) 
and Ratio to Population 



1000 



800 



600 



400 



200 




1950 1960 1970 1980 1990 *2000 *2010 

Year 

■ ■.■ ■ ■■■■■■■. I Active Physicians ^^^— Physicians: Population Ratio 

"Projected 

Source: AMA Masterfile and BHPr Physician Forecasting Model 



medical schools as well as that of international medical 
graduates (IMGs) who enter this country during their 
residency training years. 

In 1992, applicants and enrollments in allopathic and 
osteopathic medical schools continued to increase. 

Without substantial changes in the medical education 
system, enrollment in medical schools is expected to 
continue increasing, despite the apparently adequate if not 
excessive supply of physicians. This is particularly true for 
osteopathy with the opening of another osteopathic 
medical school scheduled for 1994. 



Figure 6 



Applicants and 1st Year Enrollments 
in Schools of Medicine and Osteopathy 



50 



20 



10 




j_ 



1980 1982 1984 1986 1988 1990 1992 

Year 

1st Year Enrollment ------- --•■ Applicants 



1993 • Health Personnel in the United States • Ninth Report to Congress • 53 



Upon graduation from medical school, new physicians 
enter residency programs lasting from 1 to 8 years. These 
programs prepare them to practice in one of the 26 medical 
specialties accredited by the American College of Graduate 
Medical Education. Graduates increasingly have chosen 
non-primary care specialties as a result of the high-tech 
environment in which medical education generally takes 
place and the lifestyle and financial incentives that reward 
the procedure-oriented specialties. As a result, the 
proportion of 1992 medical school graduates interested in 
pursuing primary care training had declined to 14.6 
percent. 

Concomitant with the increasing number of students 
pursuing medical careers has been an increasing number 
of residency positions. According to the Association of 
American Medical Colleges (AAMC) and the American 
Osteopathic Association (AOA), there were an estimated 
102,670 allopathic and osteopathic residents and interns in 
1992. These positions not only prepare United States 
Medical Graduates (USMGs) to enter independent 
practice, they are also the vehicle by which many 
International Medical Graduates (IMGs) first enter the 
United States and become exposed to the U.S. medical 
system. In 1991, approximately 6,000 IMGs in residency 
positions were neither citizens or permanent residents. 
Historical data shows that 33 percent of IMG medical 
residents in the United States eventually became 
permanent residents. 1 Of the 597,400 physicians practicing 
in the Nation in 1992, 22.7 percent, or 135,580 were IMGs. 



Issues 

While an examination of the absolute numbers and 
trends in physician supply and specialization patterns is 
informative, it is essential to examine the implications of 
these trends for the cost, access to, and quality of the 
Nation's health care. 

As discussed earlier, the supply of physicians and the 
physician-to-population ratio has increased dramatically 
over the past decade. Initially the expansion of the 
physician supply was viewed positively as a means of 
increasing both the minority representation within the 
physician workforce, and the access to care for 
underserved populations. In fact this has been the case 
with respect to the number of women physicians in 
allopathic and osteopathic medicine; their numbers 
increased 34 percent and 135 percent respectively between 
1981 and 1990. Other minorities have had less success. 
The percent of black physicians dropped from 3.1 to 3.0 
percent of all physicians over the same years, while the 
proportion of Hispanic physicians increased negligibly 
from 4.4 to 4.5 percent. 2 

Furthermore, the increases in the supply of minority 
physicians have led to only modest improvements in 
access to care. One reason for this may be their tendency 
to enter non-primary care specialties. Such specialists 
generally locate in the more affluent suburban and 
metropolitan areas rather than underserved ones in order 
to have the population base needed to support their 
practices. Thus, while physician representation among 
some minorities has increased, there has not been an 
adequate dispersal into rural and underserved areas. This 
is reflected in data from the Bureau of Primary Health Care 
which shows the number of primary medical care shortage 
areas increasing from 1,242 in 1978 to 2,143 in 1991, while 
the population within these shortage areas also climbed 
from the 27 million in 1978 to 36 million in 1991. 

Physician specialty distribution patterns have not only 
limited the access to care, but also may have contributed to 
higher levels of health care expenditures. An increased 
number of doctors has been linked to the over-doctoring of 



54 • Health Personnel in the United States • Ninth Report to Congress • 1993 



patients in a phenomenon known as supply-induced 
demand. Although only about one-fifth of health 
expenditures are paid directly to physicians, their impact 
on health expenditures goes beyond their billable services, 
and includes costs resulting from consultations, tests and 
ancillary services, hospitalization of patients and written 
prescriptions. Seventy to 90 percent of health care 
expenditures are estimated to be initiated by physicians. 13 
Furthermore, specialists, because of their training, appear 
to have a greater tendency to order costly tests and 
perform procedures than do their primary care 
counterparts. 

This tendency to order more tests is developed during 
specialty training which takes place in tertiary medical 
centers. There the resident is often exposed to patients 
with severe problems in more developed stages, which 
often leads the specialty physician to overestimate the 
likelihood of serious disease in unscreened populations. 
Therefore, they have a greater tendency to order costly 
diagnostic tests and perform technical procedures at a 
higher rate than primary care physicians. In addition, 
specialist services, even when identical to primary care 
practitioner services, often are more costly than their 
primary care counterparts. According to the American 
Medical Association, the mean fee for a family or general 
practice office visit with an established patient in 1990 was 
$31.24 compared to $39.87 for all physicians. 14 

Concerns over the impact of the size, distribution, and 
composition of the physician supply on access, cost, and 
quality of care led the Council on Graduate Medical 
Education (COGME) to identify seven specific physician 
workforce reform goals that could help to improve access, 
control costs and improve the quality of health care 
services. 1 One of the goals was to maintain the allopathic 
and osteopathic physician-to-population ratios at current 
levels. In addition, the Council recommended that the 



'The Council on Graduate Medical Education is a body of 17 people 
from government, academia and the private sector charged with 
providing advice and making recommendations to the Secretary of 
Health and Human Services and Congress on physician labor force 
issues.) 



United States move toward a system in which 50 percent 
of the physicians practice in the generalist disciplines of 
family practice, general internal medicine, and general 
pediatrics. This goal is aimed at reversing the current 
trend of specialization, which, if left unchanged, will lead 
to continued increases in the number and percent of 
specialists through the year 2000 and beyond. 

The Council's hope is that by holding the physician-to- 
population ratio at the current level while increasing the 
proportion of primary care physicians, greater access and 
lower costs will result. Not only do primary care 
physicians have a greater tendency to locate and serve 
underserved populations, they also tend to provide care in 
a more comprehensive, appropriate, and cost-effective 
manner. 

The cost of medical care depends not only on the type 
of physician providing the service but also the setting in 
which it is provided. Increasingly, society is focusing on 
the use of managed care as a method of controlling health 
care costs. If such a system grows, requirements for 
primary care personnel and primary care physicians are 
likely to increase. If the availability of primary care 
physicians is limited or inadequate, employers may then 
utilize physician extenders and physicians trained in 
specialty rather than primary care. Currently, some 
managed care arrangements have reported difficulties in 
recruiting properly trained primary care physicians — a 
trend that is likely to worsen if the movement toward 
specialization continues. 

The impact of current supply trends is of particular 
concern in light of trends to base more health care delivery 
on the managed care model. Assuming two-thirds of the 
population is enrolled in managed care plans and 
physician specialization patterns remain unchanged, then 
requirements for patient care physicians overall would lag 
behind the supply. As a result there would be an overall 
surplus of physicians by the year 2000, but a significant 
shortage of physicians trained in primary care. This 



2993 • Health Personnel in the United States • Ninth Report to Congress • 55 



situation would worsen by the year 2020 barring any 
changes in the health care or medical education systems. 
If changes were to occur, however, and the percent of 
medical graduates entering primary care were to increase 
to 50 percent, the overall requirements for and supply of 
physicians in both the primary care and specialty fields 
would be adequate, if not in oversupply, by the year 
2020. 5/6 

If significant changes do not occur, requirements for 
primary care physicians may exceed their supply. In this 
event, physician extenders such as nurse practitioners, 
nurse-midwives, and physician assistants, along with 
underutilized physician specialists, may be enlisted to 
provide primary care services. The use of specialists in the 
provision of primary care, however, is problematic. While 
the evidence suggests that that some specialists currently 
provide primary care, the interests and skills needed to 
provide such services differ from those required to deliver 
specialist care. Physicians who practice primary care must 
tolerate ambiguity because many problems never reach the 
stage of a diagnosis that can be coded using standard 
diagnostic nomenclature. They must be comfortable in 
establishing and maintaining relationships with patients. 
They must also be able to manage several related or 
unrelated problems at once. Over time, the problems of 
patients change and specialists, once appropriate for an 
initial problem, may be challenged beyond their skills and 
interests. While medical progress and new technologies 
provide the impetus for an increasingly specialist 
orientation; the same phenomena also calls for increasingly 
well-honed generalist skills. 



To change the future character of the physician 
workforce, changes in the educational environment are 
necessary. Because of the influence that training 
institutions have on medical students' and residents' 
specialty choice, COGME recommended that 
undergraduate and graduate medical education emphasize 
meeting regional and national physician workforce needs. 

Those needs encompass a number of issues in addition 
to the promotion of primary care. Among them is the goal 
of moving toward a physician labor force in which the 
racial/ethnic composition of the physician population 
more adequately reflects the overall population's diversity. 
It is felt that only through the diversification and 
education of the physician work force can additional 
barriers to care be removed, and access to quality care 
improved. 

Only through improvements in cultural sensitivity and 
competence of medical providers can language and 
cultural barriers to preventive and curative care be broken 
down. Understanding the setting in which the 
disadvantaged live, the environment with which they 
must contend, and the cultural attitudes which impact 
their behavior is essential to providing effective care. A 
physician may need to explain antibiotic treatment for 
strep throat to a patient who has traditionally used honey 
as a cure. Similarly, family planning counseling must 
include recognition of traditional, social and 
environmental factors shaping patient attitudes if it is be 
effective. 

One way to increase physician awareness and ability to 
deal with different cultures and communities is to cultivate 
a sense of cultural sensitivity among all physicians and to 
heighten physician awareness to the specific needs of the 
various population groups. Training in cultural sensitivity 
for all practitioners is needed since practitioners seldom 
treat individuals exclusively of their own race or ethnicity, 
nor does being of the same race or ethnicity automatically 
make a practitioner culturally competent. Nonminority 



56 • Health Personnel in the United States • Ninth Report to Congress • 2993 



practitioners should receive cultural sensitivity training 
because of the likelihood of a continued scarcity of 
minority health care providers. Finally efforts to increase 
the representation of minority groups in the physician 
workforce should continue. Currently only 10 percent of 
medical students and 7 percent of practicing physicians are 
black, Hispanic or Native American, while these groups 
comprise 22 percent of the U.S. population. 

The United States spends a larger proportion of its 
gross domestic product on health care than any other 
western nation. Despite this high level of expenditure, 
problems of inequitable, inappropriate, and inefficient care 
continue to exist. As a result, efforts are now underway to 
reform the health care system to enhance access, control 
costs and insure quality. Such changes will surely impact 
the physician workforce both in terms of the demand for 
specific specialties and the context of health care delivery. 

The key to meeting these goals is the establishment and 
implementation of a plan which will outline the Nation's 
needs while altering the educational infrastructure and 
financial reimbursement strategies required to help attain 
national workforce goals. 7 Such a plan may include 
changes in undergraduate curricula and the types of 
residencies offered or how they are financed. It may also 
include increasing financial incentives to primary care 
practitioners, particularly those serving in shortage areas, 
thereby reducing the income gap between primary care 
and specialty physicians. 



References 

1. Maun A. The Role of IMGs in the Physician Workforce. 

Presented at the Bureau of Health Professions; 
November 1992. 

2. Bureau of Labor Statistics. Data from the Current 

Population Survey. Employment and Earnings. 
Washington D.C.; U.S. Department of Labor 

3. Eisenberg JM. Doctors Decisions and the Costs of Medical 

Care. Ann Arbor, MI: Health Administration Press 
Perspectives. 

4. Center for Health Policy Research. Socioeconomic 

Characteristics of Medical Practice, 1992. Chicago, IL; 
American Medical Association; 1992. 

5. Bureau of Health Professions. Physician requirements in 

the era of managed care (Draft). Washington, D.C.; 
U.S. Department of Health and Human Services: 1993. 

6. Kindig D, Cultice J, Mullan F. The elusive generalist 

physician: can we reach a 50 percent goal. Journal of 
the American Medical Association. 1993. 

7. Council on Graduate Medical Education. Third Report: 

Improving Access to Health Care Through Physician 
Workforce Reform: Directors for the 21 Century. 
Washington, D.C.; U.S. Department of Health and 
Human Services: October 1992. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 57 



58 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Physician Assistants 

Edward S. Sekscenski, MPH; Office of Health Professions Analysis and Research, BHPr. 



The physician assistant (PA) profession in the United 
States is now more than 25 years old. The first two-year 
PA training program was established at Duke University 
in 1965 and graduated its first students in 1967. By the 
1992-93 academic year, there were 59 accredited PA 
programs with a total enrollment of 3,832 men and 
women. 1 Through June 1993, a cumulative total of 27,000 
persons had received formal PA training in the United 
States and 23,300 were currently in practice. 2 

Physician assistants are skilled members of the health 
care team who work with physicians to provide many 
types of primary and specialty services to all segments 
of the population. Recognized by law or regulation in 
49 States (except Mississippi) as well as in the District of 
Columbia, PAs are authorized to diagnose illness, order 
and interpret lab tests, establish and carry out treatment 
plans, give physical exams, suture wounds, assist in 
surgery, and provide preventive health care counseling 
under varying levels of direct and indirect physician 
supervision. In 34 States as well as D.C., physicians can 
delegate to PAs under their supervision the authority to 
prescribe varying levels of medications. Restrictions 
and limitations on PA prescriptive authority are often 
the responsibility of the State medical boards. Most 
boards have placed limitations on controlled substances, 
while some restrict PAs to prescribing specific 
medications from approved formularies. The absence of 
or limitations to prescriptive authority is an important 
barrier cited by those proposing the expansion of PA 
practice. 3 (See also the chapter on barriers to PA practice 
in this report.) 



Physician assistants are more likely than are physicians 
to practice in rural and medically underserved areas. 
Slightly more than 17 percent of PAs nationwide were 
employed in areas with populations of less than 10,000 in 
1993. This proportion is up from about 13 percent in 1989, 
but short of the 18 to 20 percent levels employed in these 
types of small communities in the late 1970's. Still, about 
34 percent of PAs worked in communities of less than 
50,000 in 1993. 

Men represented about 58 percent of practicing PAs in 
1993. The proportion of men in the profession has fallen 
consistently over the past 10 years; women have 
comprised more than half of all new PA graduates in each 
of these years. 4 About 91 percent of full-time PAs in 1993 
were white, nearly 4 percent were black, 3 percent were of 
Hispanic origin, and slightly fewer than 3 percent were 
Asian /Pacific Islanders, American Indians, or Alaskan 
natives. 

Starting salaries of new PA graduates were about $35- 
40,000, while mean salaries of practicing PAs ranged from 
$45-50,000 in 1992. Eighty-one percent of PAs worked in 
the private sector in 1992, while about 12 percent worked 
for the Federal government (including 3.2 percent in the 
Veterans Administration, 6 percent in the armed forces, 
and 0.8 percent in the Public Health Service). Seven 
percent of practicing PAs were employed by State and 
local governments. 

Supply Trends 

The total number of practicing PAs has grown rapidly 
in recent years. This has been especially true in the last 
half-decade, and indications are that this growth may 
accelerate in the near future. Admissions to and graduates 
from PA training programs have risen, as has the total 
number of such programs. In 1984-85, the 39 mostly 2-year 
PA training programs averaged 47 students a program, for 
a total of 1,833 students. During 1992-93, average 
enrollment was 65 among the 59 accredited programs for a 
total enrollment of 3,835. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 59 



Figure 7 

Total Enrollments in PA Training Programs 
1984-1993 



4000 
3800 

"g 3600 
| 3400 

1 3200 

2 3000 

o 

I 2800 

* 2600 

2400 

2200 



'84-85 '85-86 '86-87 '87-88 '88-89 '89-90 '90-91 '91-92 '92-93 
Academic Year 

Source: Association of Physician Assistant Programs 



Shifts have occurred in the distribution of PAs by 
practice setting over the past two-and-a-half decades. 
Whereas in 1974 about one-seventh of practicing PAs were 
employed in hospitals, by the mid-1980s this proportion 
had grown to a little over one-third. Since 1981, the 
proportion of PAs who are hospital-based has declined 
slightly. Although the number of PAs employed in 
hospitals continued to rise, the proportion of hospital- 
based PAs stabilized at less than 30 percent between 1990 
and 1993, in both inpatient and outpatient settings. The 
percent of PAs employed in all inpatient settings (i.e., 
hospitals and nursing homes), varies widely by State. 
According to the American Academy of Physician 
Assistants 1993 annual survey, 52 percent of non-Federally 
employed PAs in Connecticut were working in inpatient 
settings. In contrast, only 9 percent of non-Federal PAs 
practicing in California were employed in inpatient 
settings. 5 



Slight increases, meanwhile, have occurred recently in 
the proportions employed in group practice and clinic 
settings. 

About 22 percent of practicing PAs in 1992 worked in 
group practice settings in physicians' offices, while about 
10 percent were in solo practice settings. Another 6 
percent worked in outpatient clinics. 

The specialty distributions of practicing PAs also has 
changed over the past decade and a half. The proportion 
of PAs employed in the primary care specialties of family 
or general internal medicine and general pediatrics fell 
between 1978 and 1991, from 67 to 43 percent. The largest 
decline came among the family medicine specialty, whose 
share of PAs declined from 52 to 31 percent over this 
period. Data from the last two annual censuses of the 
American Academy of Physician Assistants, however, 
show some stabilization in these trends. Overall, 44 
percent of PAs designated family, general internal 
medicine, or general pediatrics as their specialties in 1993. 
Family medicine's share edged upward to 33 percent. 

Specialties that showed increases in their proportions of 
all PAs between 1978 and 1992 include the combined 
surgical subspecialties (from 4 to 10 percent), orthopedics 
(from 4 to 8 percent), emergency medicine (from 5 to 8 
percent), general surgery (from 6 to 8 percent), and 
occupational medicine (from to 4 percent). Obstetrics/ 
gynecology (at 2 and 3 percent) and internal medicine 
subspecialites (at 6 and 7 percent), meanwhile, showed 
little change over the same period. State practice acts and 
other regulatory measures appear to impact on PA 
specialty distribution. PAs in States that disallow 
authority to write prescriptions are more likely to be in 
non-primary care specialties. 7 



60 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Figure 8 

Practicing Physician Assistants in U.S. 
by Generalist/Specialty Distribution 



25000 



20000 



15000 



10000 



5000 









19,248 


22,290 

■ 






14,350 


m 


7,179 

i 


11,017 

I 


■ 



1978 1981 1984 1989 1992 

Year 



Specialist | Primary Care 

Source: American Academy of Physician Assistants 



Physician Assistant Education, Costs, 
and Funding 

Most PA training programs are 2-years in length and 
based in medical schools or schools of allied health. A few 
are based in 2-year community colleges or 4-year liberal 
arts colleges. In 1992, about 56 percent of entering PA 
students had acquired a baccalaureate degree in another 
field prior to admission, another 17 percent had earned an 
associates degree, while 7 percent had a graduate degree. 
About 44 percent of first-year PA students were 30 years of 
age or older. On average, PA students had more than four 
and one-half years of health care work experience upon 
entrance to their program. Attrition from PA programs, 
meanwhile, has declined over the past 8 years, from 14 to 
8.6 percent. 



Sixty-one percent of the PA programs in 1992 awarded 
a Bachelors of Arts degree, 13 percent awarded a masters 
degree, and 26 percent awarded associate degrees or 
certificates in 1992. Annual numbers of graduates from 
accredited PA programs have increased in each of the past 
three years to an estimated 1,594 persons in 1992. 

Total tuition costs for the 52 accredited PA and 3 
surgical assistant programs in 1992 ranged from about 
$2,300 for a 24-month in-state program to $32-35,000 at a 
few 42-month private programs (out-of-state tuition at the 
State school was $12,300). Forty of the 55 accredited PA 
programs in 1991 were supported, in part, by Title VII 
authorized grant funds, totaling $5 million in 1991. These 
Title VII grants supported about 28 percent of the PA 
training program budgets on average in 1991, down from 
an average of 41 percent in 1985, according to the 
Association of Physician Assistant Programs. 

Potential Impact of The Changing 
Health Care System 

Several factors may increase the demand for PAs, as 
well as nurse practitioners, in various sectors of the health 
care system. In hospitals, for example, it has been 
suggested that residency slots in teaching hospitals be 
limited to 110 percent of annual graduates of U.S. 
allopathic medical schools. Such a policy could result in 
the elimination of 11,000 medical residents in U.S. 
hospitals. At least some of the services formerly provided 
by these residents would likely be provided by non- 
physician practitioners such as physician's assistants. 
Expanded cut-backs in the weekly hours of medical 
residents' work, as was mandated in New York State in 
1989, could also add to the demand for PAs and other non- 
physician providers in the next few years. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 61 



There are indications that demand for PAs in outpatient 
settings could rise dramatically as the proportion of the 
population in managed care programs increases. Several 
studies have shown that PAs (as well as nurse 
practitioners) can effectively manage between 60 to 80 
percent of the primary care service needs of a population 
under certain managed-care arrangements. Factors that 
impact on the amount of substitution possible under these 
arrangements include physician specialty mix, patient mix, 
extent of professional collaboration, and workload 
scheduling. Cost factors are also expected to impact on an 
increased demand for physician assistants and other non- 
physician providers to provide primary care in these 
settings. Total compensation costs of full-time physician 
assistants was about half that of primary care physicians 
employed in managed care settings in 1992. 

In response to the expected increased demand for PA 
services proposals have been made to increase the 
numbers of practicing PAs through increased support of 
physician assistant training programs. Although methods 
for achieving these increases vary, recommendations 
include a doubling of the annual numbers of PA graduates, 
to nearly 3,500, by the year 2000 and a doubling of the 
numbers of practicing physician assistants, to 47,000, by 
year 2005. 



References 

1. Oliver D. Ninth Report on Physician Assistant Education 

Programs in the United States, 1992-93. Alexandria, VA; 
Association of Physician Assistant Programs: June 
1993. 

2. American Academy of Physician Assistants. General 

Census Data on Physician Assistants. Alexandria, VA; 
1992. 

3. Willis J. Barriers to physician assistant practice in rural 

settings, journal of the American Academy of Physician 
Assistants. 1993. and Cawley, J. Physician Assistants in 
the Health Care Work Force. Presented at the 
Association of Academic Health Centers Workshop on 
Physician Assistants and Primary Care; April 13, 1993; 
Washington, DC. 

4. American Academy of Physician Assistants. General 

Census Data on Physician Assistants. Alexandria, VA; 
1982-1992. and Oliver D. Ninth Report on Physician 
Assistant Education Programs in the United States, 1992- 
93. Alexandria, VA; Association of Physician Assistant 
Programs: 1982-1992. 

5. American Academy of Physician Assistants, 1993 

Annual Survey. Special estimation table produced by 
the AAPA; August 1993. 

6. Knickman JR, et al. The potential for using non- 

physicians to compensate for reduced availability of 
residents. Academic Medicine. July 1993:429-438. 

7. Willis J. Barriers to Physician Assistant Practice in 

Primary Care and Medically Underserved Areas: 
Background. Presented at the 3rd Annual Primary 
Care Conference; January 11, 1993; Agency of Health 
Care Policy and Research, Atlanta, GA. 



62 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Dentists 



Stephen Tise, Office of Health Professions Analysis and Research, BHPr. 



The American Dental Association's (ADA) 1991 census 
estimated that there were 155,000 active dentists in 1991, a 
number that varied somewhat from the 162,000 estimated 
by the Bureau of Labor Statistics' Current Population 
Survey in 1992.' The Bureau of Labor Statistics projects the 
demand for new dentists will grow by about 12 percent 
between 1990 and 2005: slower than the 20 percent overall 
growth projected for all occupations. 2 

As the following graph shows, enrollments and 
graduates declined during much of the 1980's. The drop 
has been attributed to a number of factors including a 
decline in the college-aged population, increased 
educational costs, and a perceived oversupply 
characterized by an increasing practitioner-to-population 
ratio. More recently, however, enrollments have remained 
steady and showed a slight increase in the 1992-93 
academic year. Future enrollment trends, however, 



Figure 9 

Dental School Enrollments and Graduates 



25 



20 



15 



£10 



J I L 



J I L 



1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 
Year 

Enrollments c - - Graduates 

Source: American Dental Association 



depend partly on whether any of the remaining dental 
schools close. Currently, there are 54 programs, down 
from the all time high of 60 that existed up to the 1985-86 
school year. Many programs, especially private ones, have 
experienced financial problems in recent years and any 
additional closings will likely come from this group. 

Changing Disease Patterns and 
Demographics 

While the economic demand for dental care is 
apparently being met, the true need for services clearly is 
not. Those having the resources— out-of-pocket cash or 
insurance — have little problem receiving treatment; those 
lacking such resources often receive fewer services, which 
when provided are often only palliative. Assuming no 
change in the way current dental care is financed, several 
factors may tend to exacerbate the gap between those who 
receive care and those who do not. 

1. Although the fluoridation of water has reduced the 
number of caries and fillings needing replacement, 75 
percent of dental caries in children are concentrated in 25 
percent of the population, with disease levels .generally 
higher among the minorities. 3 

2. Minority populations, more likely to be uninsured 
and unable to afford dental care, are expected to grow 
between now and the year 2020, exacerbating the gap 
between true need and economic demand. 9 

3. The adult population is a growing proportion of the 
total population, and is at greater risk for gingivitis and 
adult-onset periodontis which affect over half of the 
population between 18 and 64 years of age, and are major 
contributors to tooth loss. 4 



1993 • Health Personnel in the United States • Ninth Report to Congress • 63 



i^^^m^^^^^^^^M^^^^^^^^^^^H^^H 



Issues 

Despite improvements in the nation's overall dental 
health, a sizable proportion of the population lacks 
adequate dental care, and oral health problems, which 
often are not self-limiting, remain prevalent. For instance, 
84 percent of children still experience tooth decay by the 
time they leave high school; 40 to 70 percent of adults have 
periodontal disease; and more than a third of those over 65 
have no natural teeth. 3/4/5 In addition, some 30,000 
Americans are diagnosed with oral cancer each year and 
about 8,000 die— more than those claimed by cervical 
cancer. 6 Helping to make possible these conditions is the 
fact that 40 percent of the population fails to receive any 
dental care each year, a situation made more unfortunate 
because many dental problems are easily avoided through 
simple preventive care. On the other hand, unlike many 
medical problems, they are not self-limiting; once they 
occur they tend to become worse over time. 5 

While dentistry lacks medicine's major problems of 
over-specialization and geographic shortages, it has the 
problem of being financially inaccessible. Currently, less 
than half of the population has private dental insurance, 
and Federal and State funds pay for less than 2 percent of 
all dental care. 7/8 Medicare, for instance, does not pay for 
dental services for those over 65, an age when such 
services are becoming particularly important and 
individuals are less likely to have private insurance. The 
lack of insurance or out-of-pocket cash to pay for regular 
preventive services condemns many to wait too long and 
then only receive services in a hospital emergency room 
where the treatment often is only palliative and not 
curative. 



Why is dentistry so inaccessible? Unlike other health 
care providers whose practices are closely intertwined 
with other practitioners, regulatory bodies, and 
community agencies, the dental profession has remained 
relatively autonomous. 8 Dentistry's autonomy has fostered 
the impression that oral health care is more a discretionary 
service than an integral part of health care: a belief 
supported in part by the fact that the profession is less 
involved in Federal and State programs, such as Medicare 
or Medicaid, than other health professions. Public health 
professionals and other agents representing society are 
now attempting to reverse this professional and 
institutional inertia. 

Interestingly, the infrastructure needed to expand the 
delivery of dental services already exists. One quarter of 
all health care establishments are dentists offices, and as of 
December 31, 1992, there were only 967 health professional 
shortage areas for dentists compared to over 2,271 for 
primary care physicians. 9710 



64 • Health Personnel in the United States • Ninth Report to Congress • 1993 



References 

1. Office of Employment and Unemployment Statistics. 

Employment and Earnings. Washington, DC: U.S. 
Department of Labor, Bureau of Labor Statistics; 
January 1993. 

2. Silvestri G, Lukasiewicz J. Occupational employment 

projections. Monthly Labor Review. November 1991. 

3. Epidemiology and Oral Disease Prevention Program. 

Oral health of United States children: the national survey 
of dental caries in U.S. school children: 1986-87. Bethesda, 
MD: National Institute of Dental Research; September 
1989. NIH Pub. No. 89-2247. 

4. Epidemiology and Oral Disease Prevention Program. 

Oral health of United States adults: the national survey of 
dental caries in U.S. employed adults and seniors: 1985-86. 
Bethesda, MD: National Institute of Dental Research; 
August 1987. NIH Pub. No. 87-2868. 

5. Bloom, B gift HX, Jack SS. Dental Services and Oral Health; 

United States, 1989. Hyattsville, MD: National Center 
for Health Statistics; 1992. Vital Health Stat 
1992;10:183. 

6. American Cancer Society. Cancer facts and figures-1992. 

Atlanta, GA: American Cancer Society, 1992. 

7. Health Insurance Association of America. Source book of 

health insurance data. Washington, DC: 1985. 

8. O'Neil EH. Health professions education for the future: 

schools in service to the nation. San Francisco, CA: Pew 
Health Professions Commission; 1993. 

9. Office of Employment Projections. Career guide to 

industries. Washington, DC: U.S. Department of Labor, 
Bureau of Labor Statistics; September 1992. 

10. Bureau of Primary Health Care. Selected statistics on 

health professional shortage areas. Washington, DC: U.S. 
Department of Health and Human Services; December 
1992. 



2993 • Health Personnel in the United States • Ninth Report to Congress • 65 



^m 



66 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Nurses 

Evelyn B. Moses, Division of Nursing, BHPr. 



Nursing constitutes the largest segment of those 
employed in health care. Nursing personnel are divided 
into three occupational groups: registered nurses(RNs), 
licensed practical /vocational nursesKLPN/VNs), and 
assistive nursing personnel. 

Among the three occupational groups, registered 
nurses are the most numerous. Registered nurses are 
individuals who hold current licenses to practice within 
the scope of professional nursing in at least one 
jurisdiction of the United States. Their responsibilities in 
the health care system are wide-ranging. The majority are 
responsible for the provision of direct patient care in 
institutional, public or community health, home health, or 
ambulatory care settings. Advanced practice RNs also 
provide specialized or primary patient care to clients either 
as self-employed practitioners or as employees in 
organized health care delivery centers. Other RNs 
function as managers and directors of complex nursing 
care systems or as teachers of nursing to the variety of 
nursing groups. An estimated 1,853,024 registered nurses 
were employed in nursing positions in the United States in 
March 1992 according to the latest National Sample Survey 
of Registered Nurses. 1 

Licensed practical nurses are individuals who hold 
current licenses to practice within the scope of practical or 
vocational nursing in at least one jurisdiction of the United 
States. LPN/VNs function primarily as providers of direct 
patient care in institutionalized settings. The smallest of 
the three occupational groups in nursing, it is estimated 
that, as of December 31, 1991, there were 555,000 employed 
LPN/VNs in the United States. 2 

Assistive nursing personnel are unlicensed individuals 
who assist nursing staff in the provision of basic care to 
clients and who work under the supervision of licensed 
nursing personnel. Included in this occupational group are 
nurse aides, nursing assistants, orderlies, attendants, and 



1 In two States, California and Texas, these nurses are called 
vocational nurses. In other jurisdictions, they are known as practical 
nurses. In the remaining parts of this section licensed practical/ 
vocational nurses with be referred to as licensed practical 
nurses(LPNs). 



personal care and home health aides. While no overall 
single estimate of the number of individuals within this 
occupational group is available, based on data from a 
variety of sources, they probably number about 1-1.1 
million individuals. 3 

Distribution within the Health Care System 

Data on the use of nursing personnel in the health care 
arena have shown an increasing reliance on registered 
nurses in comparison to the other two occupational 
groups. Hospitals, which employ a substantial proportion 
of the personnel within each of the nursing occupational 
groups, have increased their employment of registered 
nurses while generally decreasing their employment of 
licensed practical nurses. Although in recent years there 
has been an increase in the number of assistive nursing 
personnel employed by hospitals, the number is still 
lower than it was in the early 1980s.. 



Figure 10 

Full-Time Equivalent Nursing Personnel 
Employed by Community Hospitals 1981-1991 



1000 



800 



600 



400 



200 



Registered Nurses 



Assistive Nursing Personnel 



-Licensed Practical Nurses 



J I I I I L 



1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 
Year 

Source: AMA's Committee on Allied Health Education and Accreditation 



1993 • Health Personnel in the United States • Ninth Report to Congress • 67 



■H^^BHMM^^^^^HM 



Assistive nursing personnel are the predominant 
employees in nursing homes. However, although current 
data for all types of nursing personnel in nursing homes 
are not available at this time, recent regulatory 
requirements stemming from a concern about the quality 
of care in these facilities have probably led to an increase 
in the employment of licensed nursing personnel. The 
National Sample Survey of Registered Nurses indicates 
that, between 1988 and 1992, the number of registered 
nurses practicing in nursing homes increased 17 percent, 
proportionately more than the 14 percent increase shown 
in the number of all employed RNs regardless of practice 
setting. In contrast, between 1984 and 1988, the number of 
registered nurses in nursing homes decreased despite an 
increase in the overall supply of RNs. 4 

The increased use of registered nurses to provide health 
care also has been stimulated by expansion of 
noninstitutionalized care. Health care provided on an 
ambulatory basis, in physicians' offices or clinic settings, 
or in patients' homes is far more likely to be provided by 
registered nurses than by other nursing occupational 
groups. Based on the 1992 National Sample Survey of 
Registered Nurses, there was a substantial increase in the 
number of RNs working in public /community health 
settings. The number of RNs working in these settings 
increased about 30 percent between 1988 and 1992, 
compared to an increase of about 11 percent in hospitals. 
And, in hospitals, the number of RNs in outpatient 
departments increased about 68 percent compared to an 
increase of about 6 percent for nurses working in in- 
patient bed units. Among the various settings which 
constitute part of the public /community health area, the 
number of RNs in settings providing home health care 
almost doubled between 1988 and 1992. 

In addition to registered nurses, home health agencies 
also employ home health aides in significant numbers. 
Data from the 1991 Provider Inventory from the National 
Center for Health Statistics show that, in Medicare- 
certified home health care agencies, there were about 
157,000 full-time equivalent nursing personnel. Fifty-three 
percent of these were licensed nursing personnel, mostly 



Figure 11 



Full-Time Equivalent Nursing Personnel 
in Medicare-Certified Home Health Agencies 



55,199 

Home Health 

Aide 




18,891 Nursing Aide 



15,272 LPN 



Source: Based on data collected by the National Center tor Health Statistics. 



registered nurses. Forty-seven percent were assistive 
nursing personnel, mostly home health aides. 5 

Influences on the Current Supply of 
Registered Nurses 

The last two reports to Congress pointed out the 
significant shortage in the supply of registered nurses to 
fill the demand for their services. 677 More recent indicators 
suggest that for the present time the shortage might have 
eased. Data from the 1991 Hospital Nursing Personnel 
Survey indicate a decline in the national average RN 
vacancy rate from 11 percent in 1990 to 8.7 percent in 1991. 
That study also suggests that there was a shift in the 
hospitals' perception of RN shortages. For example, only 8 
percent of the hospitals responding to the survey reported 
"severe" shortages compared to 16 percent in 1990. 
Substantial declines also were noted for hospitals 
indicating "moderate" shortages, from 51 percent of the 
respondents in 1990 to 35 percent in 1991. Further, the 
study showed some improvement in the time it took to fill 
RN positions. 8 



68 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Data are not available to indicate whether there have 
been shifts in the vacancy rates for other employment 
settings. However, the increases noted in the number of 
RNs in nursing homes and the substantial growth in the 
number in home health agencies suggest that shortages in 
those areas may have eased as well. 

A number of recent occurrences may have contributed 
to the decrease in the severity of the nursing shortage. 
While the total number of graduates from basic nursing 
education programs decreased significantly in the mid- 
eighties, that trend has been reversed. In the 1990-91 
academic year, the number of graduates totalled 72,230, 9.3 
percent more than the number in 1989-90. 9 Preliminary, as 
yet unpublished data for 1991-92, show an even larger 
increase, about 13 percent, for a total of almost 82,000 
graduates in that academic year. 



The March 1992 National Sample Survey of Registered 
Nurses showed an increase in the proportion of those with 
licenses to practice as registered nurses who were 
employed in nursing. In 1992, almost 83 percent of the 
RNs were employed in nursing compared to 80 percent in 
1988. The total RN population increased 10 percent, 
however, the number of employed RNs increased 14 
percent, from 1,627,035 to 1,853,024. RNs were also more 
likely to be employed on a full-time rather than part-time 
basis. 

The average salary of an RN employed in nursing on a 
full-time basis in March 1992 was $37,738, 33 percent more 
than in March 1988. Between November 1984 and March 
1988 the average salary of a full-time employed RN 
increased only 21 percent. 





Figure 12 




Graduations from Basic Programs 




Preparing for RN Licensure 


100000 




80000 




1 60000 

CO 
C/) 

=3 
O 




— 40000 




20000 



i 


1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 




Year 




mhbh BBHHR hhhh 

Hi Baccalaure Associate 9IH Diploma 




Source: American Dental Association 



Figure 13 

Registered Nurse Population 
by Nursing Employment Status 



2500000 



2000000 



1500000 



1000000 



500000 





1992 



Not 
Employed 



Source: HRSA, BHPr, Division of Nursing 



Employed 
Part-Time 



Employed 
Full-Time 



1993 • Health Personnel in the United States • Ninth Report to Congress • 69 



Outlook for the Future 

The extent to which the current picture will be reflected 
in the future needs to be considered from a variety of 
perspectives. The projections of future graduates from 
basic nursing educational programs contained in the 
Eighth Report to Congress predicted decreases in the annual 
number of graduates in the future rather than increases. 
Those conclusions were drawn following a period of 
declining growth rates and a continuous five-year decrease 
in the number of annual graduations. When the more 
recent graduation numbers are taken into account a 
somewhat more optimistic picture for the future can be 
drawn, one which shows some gains over the years in the 
number of graduates rather than losses. However, there 
are many factors affecting the choices individuals might 
make about becoming nurses, many of which themselves 
are difficult to predict. These factors need to be considered 
when judging which scenario is more likely. 

In any event, the number of new graduates available 
each year is only part of the picture of how many RNs will 
be available to provide for the health care needs of the 
population. To be taken into consideration as well is the 
number of those already in the workforce who will 
continue to be a part of that workforce. Increasing 
numbers of the new graduates come from the older 
segments of the population. The average age of the 
registered nurse population continues to rise. Continuing 
a trend noted in prior National Sample Surveys of 
Registered Nurses, there were 110,000 fewer registered 
nurses under the age of 35 in 1992 than there were in 1988, 
a 16 percent drop, despite the increase in the overall nurse 
population. 

The Eighth Report to Congress, taking into account both 
the decreasing numbers of new graduates available each 
year along with the increasing age of the new graduates 
and of the total registered nurse population, forecast a 
decrease shortly after the turn of the century in the 
number of RNs available for the workforce. New 
projections of what the supply of registered nurses might 
be in the future, taking into account current graduation 
levels and the somewhat higher than anticipated 



Figure 14 

Age Distribution of Registered Nurse 
Population, March 1988 and 1992 



bUU 




4UU 


V ^k 1992 


3UU 




2UU 


1988 


"^^^ 


—■» 


IUU 


i i i i i i 


i i 


i i 



>25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ 



Source: HRSA, Division of Nursing, BHPr 



proportion of the registered nurse population that is part 
of the supply, might paint a less pessimistic picture than 
the earlier one. However, the increasing age level of RNs 
will continue to have the effect of diminishing the growth 
rate in the nurse supply, particularly in a climate of 
continuing and increasing demands. 

Projections of the future demand for registered nurses, 
along with those for the other groups of nursing 
personnel, reported in the Eighth Report to Congress, show 
increasing future requirements. These projections also 
need to be reexamined in the light of more recent data on 
the distribution and use of nursing personnel within the 
various segments of the health care system, the 
restructuring of the health care system being carried out in 
the States and by private sector health care providers, and 
the provision of health care to those within the population 
currently without access because of lack of facilities or 
financial ability. 



70 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Conclusions 

Factors such as the expansion of the availability of 
primary care, including the most cost-effective approaches 
to the delivery of such care; the expansion of the provision 
of care in nontraditional settings and less structured 
environments; improved technologies and care models 
leading to increased complexity; the aging of the 
population, and the emphasis on prevention and health 
promotion all play a role in the requirements for nursing 
personnel. These factors affect not only the numbers that 
might be required but also the qualitative aspects that 
might be desired of nursing personnel. While other areas 
of this report elaborate on this subject, it is important to 
include in this overview conclusions of the impact of the 
issues examined in those sections on the composition of 
the nurse workforce. 

The section on the appropriate nurse workforce for 
current and future health care delivery notes that key to 
the provision of a nurse workforce adequately prepared to 
meet the future requirements is nursing education. Future 
visions of the health care system require registered nurses 
educated in the broad-based aspects of the delivery of care. 
Baccalaureate education is more likely to provide this 
perspective than is diploma or associate degree education. 
Yet almost two-thirds of the new entrants into nursing 
each year come from associate degree programs. 
Increasingly, nursing in its expanded advanced practice 
role is being looked to for the provision of cost-effective 
care to the underserved. Baccalaureate preparation is 
necessary as a foundation for the graduate level education 
for this expanded role. 



In another section of this report, the issue of the barriers 
to practice of nurses in the advanced practice roles of 
nurse practitioner and nurse-midwife is discussed. As 
indicated there, such barriers affect the ability of these 
practitioners to increase access to quality care. As States 
and other entities continue moving toward changes in the 
health care system these practitioners take on increasing 
importance as a source of primary care to the population. 
Therefore, in addition to an education system that can 
produce a sufficient number of appropriately trained 
nurses, also important is the enabling of advanced practice 
nurses to function at their full scope. 

Recommendations: 

■ Federal resources and program initiatives should be 
strategically targeted to assure the development of a 
nursing workforce prepared to meet the demands for 
services in a changing health care system. 

■ Federal efforts relating to nursing education should 
focus on assuring a nursing workforce appropriate for the 
changing health care model emphasizing community- 
based primary health care. 

■ Barriers to practice should be removed to enable 
health care workers, including nurses, to function in their 
full scope of practice. 

■ Development and monitoring of the nursing 
workforce should be supported by targeted national 
analytic efforts. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 71 



References 

1. Bureau of Health Professions. The Registered Nurse 

Population, March 1992, Findings from the National 
Sample Survey of Registered Nurses. Washington D.C.: 
U.S. Department of Health and Human Services; 
(to be published). 

2. Estimate of Division of Nursing, based on Levine 

Associates. Feasibility of Developing LPNILVN Estimates 
Using Secondary Data. HRSA Contract No. 240-91-0033, 
unpublished report. 

3. Vector Research, Inc. Final Report on the Nursing Demand 

Model and Final Report on Projections of the Future 
Demand for Nursing Personnel Using the Nursing 
Demand Model (NDM). Rockville, MD; Vector 
Research; November 1991, unpublished. 

4. Bureau of Health Professions. The Registered Nurse 

Population, Findings from the National Sample Survey of 
Registered Nurses, March 1988. Washington, D.C.: 
U.S.Department of Health and Human Services; June 
1990. 

5. Compiled by Division of Nursing from data provided by 

U.S. Department of Health and Human Services, 
National Center for Health Statistics, 1991 National 
Health Provider Inventory Survey. 

6. Bureau of Health Professions. Seventh Report to the 

President and Congress on the Status of Health Personnel 
in the United States. Washington D.C.: U.S. Department 
of Health and Human Services; March 1990. DHHS 
Publication No. HRS-P-OD-90-1. 



7. Bureau of Health Professions. Health Personnel in the 

United States, Eighth Report to Congress. Washington 
D.C.: U.S. Department of Health and Human Services, 
1991; September 1992. DHHS Publication No. HRS-P- 
OD-92-1. 

8. American Hospital Association, Executive Summary: 

Report of the 1991 Hospital Nursing Personnel Survey. 

9. Division of Research. Nursing Datasource 1992, Volume I, 

Trends in Contemporary Nursing Education. New York, 
NY: National League for Nursing Publication; No. 19- 
2480. 



72 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Allied Health Introduction 

Stephen Tise, Office of Health Professions Analysis and Research, BHPr. 



The Bureau of Health Professions defines the allied 
health professions as those requiring professional training 
at the post-secondary school level, excluding nurses, 
physicians, dentists and others trained to diagnose disease. 
Employment in these occupations, including, for example, 
physical, respiratory and occupational therapists, 
dietitians and medical records personnel, grew 42 percent 
from 1983 through 1992, from 1.5 to 2.1 million. The allied 
health growth rate was about two-and-a-half times that of 
total employment during the same time period. 1 

Further, the Bureau of Labor Statistics (BLS) projects 
employment among the health occupations to grow by 50 
percent between 1990 and 2005, almost two-and-a-half 
times the 20 percent rate projected for all occupations and 
significantly higher that 29 percent rate projected for the 
group of professions comprising allopathic, osteopathic, 
and veterinary medicine, dentistry, optometry, and 
podiatry. 2 It is even higher than the rapidly growing field 
of nursing, where a 44 percent growth rate is forecast. 



Figure 15 

Projected Growth Rates: 1990-2005 and 
2005 Employment Levels in Millions 



g 30 




Allied 
Health 



Cursing Diagnosing Total Workforce 

Occupations Occupations 



I Growth | 2005 Employment in Millions 

Source: U.S. Department of Labor, BLS, Office of Employment Projections 



The projected rapid growth for allied health care 
workers is based largely on expectations that new 
technologies, new equipment, and a growing and aging 
population will continue to create additional demand for 
health care services and workers. It is expected that those 
advances, while they save lives and prevent disabilities, 
will leave many patients with extensive rehabilitative 
needs. Furthermore, as new diagnostic equipment 
becomes available, the demand for those who operate it 
will increase, as it did for CAT and MRI scan personnel. 
Probably the greatest contributor to demand, however, 
will be sheer population growth, particularly among the 
aged, who are are more likely to have acute and chronic 
health problems. 

Concerns common to the allied health fields include: 

■ Shortages. The requirements for many allied health 
occupations appears greater than the supply. 

■ Scope of work. Many occupations need to change or 
expand their scope of work to achieve cost-efficiencies and 
provide better access to care. 

■ Educational requirements. A trend toward 
increasing educational requirements prior to establishing 
the need or efficacy has resulted in concerns that 
unnecessary cost increases may result without 
improvements in care. 

■ Technology. New technology is expected to increase 
the demand for allied health in some areas by inventing 
new capabilities or services, while decreasing demand in 
other areas by making tasks simpler. 

This section will examine these and other issues that 
may affect the allied health professions and their role in 
the Nation's health care system. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 73 



References 

1. Bureau of Labor Statistics, Employment and Earnings. 

Washington, DC: U.S. Department of Labor; January 
issues. 

2. Silvestri G, Lukasiewicz J. Occupational employment 

projections. Monthly Labor Review. November 1991. 



74 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Dental Hygienists 



Dental hygienists are oral health professionals, licensed 
in dental hygiene who provide educational, preventive, 
and therapeutic oral health services. The Bureau of Labor 
Statistics (BLS) estimates that dental hygienists held about 
74,000 jobs in 1992. 1 The BLS also projects a 41 percent 
increase in jobs for the occupation between 1990 and 2005, 
much higher than the average 20 percent growth projected 
for the nation as a whole. 2 The American Dental 
Hygienists Association estimates that approximately 
78,000 of about 100,000 registered dental hygienists (RDH) 
were actively providing dental hygiene services in 1993. 
Only about 52 percent of RDHs work full-time as 
clinicians; many of the rest work part-time at more than 
one job. Currently, there appears to be no shortage of 
hygienists. 

Issues 

Dental hygienists are the only licensed professionals 
whose scope of practice and program accreditation is 
controlled by their employers — dentists. The 
appropriateness of this has been challenged in a number of 
States by legislative proposals that would establish 
separate State licensing boards for hygienists. In addition 
to developing separate State licensing boards, proposals 
have been advanced to ensure that course requirements for 
dental hygiene education programs are regularly updated 
to accurately reflect the needs and trends of society. 

Presently, dental hygiene services are largely confined 
to private dental offices because of supervision 
requirements which differ from State to State and hinder 
hygienists' ability to disperse throughout the community 
and thereby improve access to oral health care. This is 
despite the fact that State specific licensing requirements 
for dental hygienists ensure that by granting a license, 



dental hygienists have demonstrated to the State's 
satisfaction that, within their scope of practice, the public's 
health, safety, and welfare, will be ensured. In addition, 
dental hygienists, carry their own malpractice insurance. 
These educational and professional requirements suggest 
dental hygienists possess the ability to practice without 
supervision. In fact, over 40 States permit the dental 
hygienists to provide services under "general 
supervision", meaning the physical presence of a 
supervising dentist is not required. 

A recent study found that dental hygienists in 
independent practice provided greater access to 
underserved areas, did so at less cost, and provided very 
high percentages of acceptable care, and that oral health 
care provided by dental hygienists compared favorably to 
the oral health care provided by a comparison group of 
dentists. 3 A 1989 Institute of Medicine study reported "the 
opportunities for hygienist employment outside dental 
offices today are limited by regulations that require them 
to work on site with dentists. Thus, populations such as 
the elderly in long-term care facilities and physically and 
mentally retarded people in institutions, whose access to 
dental care is limited by their lack of mobility, cannot be 
served by hygienists alone." 4 Further, a report of the 
Federal Trade Commission found that increased use of 
dental hygiene services would decrease costs to the 
consumer and improve access, without compromising 
quality. 5 

For its part, the ADA has opposed self-regulatory 
proposals arguing that it would lead to independent 
practice and that "unsupervised or independent practice 
by dental hygienists reduces the quality of oral health care 
and seriously increases risks to the patient." 6 These 
claims, however, appear unsupported by any data. 

For the professions, the controversy over self-regulation 
is largely one of autonomy and control. For the public, it is 
whether self-regulation would assure the provision of 
quality dental hygiene services while increasing access and 
reducing costs. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 75 



References 

1. Office of Employment and Unemployment Statistics. 

Employment and Earnings. Washington, DC: U.S. 
Department of Labor, Bureau of Labor Statistics; 
January 1993. 

2. Silvestri G, Lukasiewicz J. Occupational employment 

projections. Monthly labor Review. November 1991. 

3. Freed J, Perry D. Final report, access utilization and quality 

of independent dental hygiene practices. Health 
Manpower Pilot Project Program #139 of California 
Office of Statewide Health Planning and 
Development. March 18, 1992. 

4. Institute of Medicine. Allied Health Services; Avoiding 

Crises. Washington, D.C.: National Academy of 
Sciences; 1989; p. 108. 

5. Liang J, Ogur D. Restrictions on Dental Auxiliaries: An 

Economic Policy Analysis. Washington, D.C.: Federal 
Trade Commission; May 1987; p. 2. 

6. American Dental Association House of Delegates, 

Comprehensive policy statement on dental auxiliaries, 
Adopted 1988. 



76 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Physical Therapists 



Physical therapists held about 88,000 in 1990. This 
number is projected to grow to about 155,000 in 2005, a 76 
percent increase that would make it one of the fastest- 
growing occupations in the country. 1 Factors contributing 
to both recent and future demand for PTs include new 
technologies that save lives but leave people in need of 
rehabilitation, and therapeutic advances that allow 
treatment of a wider range of conditions. Also 
contributing to demand is the rapidly growing population 
of those over 65 who suffer disproportionately from 
chronic conditions. Contributing to future demand will be 
the pool of aging baby boomers becoming more 
susceptible to disease and disability. 

Issues 

The most important issue related to PTs and the health 
of the nation is one of supply and demand. There is 
evidence that a significant shortage exists despite 
continued growth in both programs and graduates. 
Indicators of increased demand include: 

■ The AHA's finding that PTs had the highest FTE 
vacancy rate of any occupation in 1991 (16.6 percent). 2 
Currently, hospitals employ about one-third of all PTs. 

■ Rapid salary increases. According to Current 
Population Survey data from the Bureau of Labor Statistics 
(BLS), the median weekly earnings of PTs who worked full 
time increased 57 percent between 1984 and 1991, 
compared to a 32 percent increase for all occupations. 3 

■ A 33 percent growth in educational programs, from 
107 in 1984 to 136 in 1992, and the development of 22 new 
programs. This is rapid growth compared to almost no 
growth in the overall number of accredited allied health 
programs over the same period. 4 

While a quick reduction in the shortage is not likely, 
there are indications that the disparity between supply and 
demand will narrow, particularly given the number of new 
training programs. 5 However, much of any increase in 
supply will go toward replacing those who leave the 
profession to retire or to seek another type of employment. 
Using BLS separation data for "All Therapists" as a proxy 



for physical therapists, roughly one third (29,300) of 
physical therapists will have left the occupation by 2005. 6 
Thus, roughly one-third or six-and-a-half years worth of 
graduates (at the 1990-91 level of 4,500 a year) will go to 
replace those who leave. The rest will fill long-standing 
vacancies and new jobs. 

Assuming the annual number of graduates remains 
constant at the 1990-91 level and that one-third of the 1990 
supply needs replacement by 2005, then rough calculations 
show that the supply of PTs would fall short of BLS's 
projected demand of 155,000 in 2005. The addition of new 
programs is therefore encouraging and should add 
considerably to the previous growth in PT graduates. 
While the development of new educational programs is 
encouraging, the programs face shortages of qualified 
faculty, inadequate physical space, and tight fiscal 
constraints in many universities. 



Figure 16 

Graduates of PT Programs 
1981-1991 



5000 



4000 



3000 



2000 



i i i i I I I I L 



1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 
Year 

Source: American Physical Therapy Association 
1982 ant) 1986 data is interpolated 



2993 • Health Personnel in the United States • Ninth Report to Congress • 77 



A number of issues could affect PT supply and 
demand. Demand could increase if more States allow PTs 
to diagnose and treat without a physician referral. On the 
other hand the excess demand for PT has resulted in 
greater utilization of PT assistants as PT "extenders", 
although some large insurance companies do not 
reimburse for PT assistant services. The extent this has 
limited the role of PT assistants and affected their ability to 
provide services is not well understood. 

An issue that could affect whether existing demand is 
met is a 1984 Medicare regulation limiting the rate at 
which PTs who work as independent contractors can 
increase their charges. The rate has not been updated, and 
Medicare payments now lag behind those paid by private 
payers. As a result, fewer PT contractors are willing to 
work in facilities that are heavily reliant on Medicare, such 
as nursing homes, which may find it hard to comply with 
laws mandating the provision of therapy services. 



References 

1. Silvestri G, Lukasiewicz }. Occupational employment 

projections. Monthly labor Review. November 1991. 

2. Kreml BB. Survey of Human Resources-1991. Chicago, IL: 

American Hospital Association; 1992. 

3. Office of Employment and Unemployment Statistics. 

Unpublished data from the Current Population 
Survey. Washington, DC: U.S. Department of Labor, 
Bureau of Labor Statistics; Selected years. 

4. Committee on Allied Health Education and 

Accreditation. Allied Health Education Directory: 13th 
and 20 Editions. Chicago, IL: American Medical 
Association; 1985 and 1992. 

5. Bureau of Labor Statistics. Occupational Outlook Handbook 

1992-93. Washington, D.C.: U.S. Department of Labor; 
May 1992. Bulletin 2400. 

6. Bureau of Labor Statistics. Total and Net Occupational 

Separations: A Report on Recent Research. Washington, 
D.C.: U.S. Department of Labor; August, 1991. 



78 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Occupational Therapists 



Jobs for occupational therapists (OTs) are expected to 
increase from 36,000 in 1990 to 56,000 in 2005, a growth 
rate of 55 percent, making it one of the 20 fastest growing 
occupations in the economy. 1 

Issues 

The primary issue facing OTs is that demand for their 
services appears to exceed the available supply. Indicators 
that help put the supply and demand situation into 
perspective include the following: 

■ An AHA survey showing a FTE hospital vacancy rate 
of 14.2 percent in 1991; a rate second only to that of 
physical therapists. 2 Hospitals employed 40 percent of 
OTs in 1990. 3 

■ The median weekly earnings of OTs who usually 
worked full-time increased 71 percent between 1984 and 
1991, faster than the 32 percent growth for all occupations. 4 

■ A 32 percent growth in the number of educational 
programs, from 56 in 1983-84 to 74 in 1990-91. This is 
rapid growth compared to almost no growth for the sum 
of all accredited allied health programs, and indicates a 
response by schools to increasing demand from 
employers. 5 Also, 16 programs were in development in 
1993. 

As the following graph illustrates, the annual number 
of graduates increased 27 percent between 1985-86 and 
1990-91. During the same time, enrollments grew 47 
percent, with much of the increase occurring in the three 
most recent years. This suggests that the annual number 
of graduates, which has remained relatively constant at 
about 2,500, should start to increase significantly in the 
next few years. 

A significant proportion of any new graduating class, 
however, goes to replacing those who permanently leave 
the occupation. Using BLS data for "All Therapists" as a 
proxy for OTs, roughly one-third of OTs practicing in 1990 
(about 12,000) will have permanently left the occupation 
by 2005. 6 Thus, almost 5 years worth of graduates (at the 
1990-91 level of 2,500 a year) will go to replace those who 





Figure 17 

Enrollments and Graduates of 
OccupationaS Therapy Programs 


10000 
8000 
6000 
4000 
2000 












i i i i i i 





1985-86 1986-87 1987-88 1988-89 1989-90 1990-91 
Year 

Enrollments z=z Graduates 

Source: AMA's Committee on Allied Health Education and Accreditation 



leave the occupation between 1990 and 2005. The rest will 
go to eliminate existing vacancies and fill new jobs. 
Assuming the annual number of graduates remains 
constant at the 1990-91 level and that one third of the 1990 
supply needs replacement by 2005, then rough calculations 
show that the supply will exceed BLS's 2005 projection of 
56,000 jobs. Such calculations are just estimates, however, 
and serve more as an indicator of whether the gap between 
supply and demand is currently narrowing than an 
accurate estimate of what will occur. While the gap would 
appear to be narrowing, it is encouraging that the number 
of graduates will increase soon and that an 16 additional 
programs are in development, although finding an 
adequate supply of faculty has been a problem, according 
toAOTA. 



2993 • Health Personnel in the United States • Ninth Report to Congress • 79 



^^^m 



A number of issues could affect demand for OTs. 
Demand would increase, for instance, if Medicare begins 
reimbursing OTs directly for home health services. 
Demand also would increase if more States allow OTs to 
treat without a physician's referral. 

Passage of the Americans with Disabilities Act (PL 101- 
336) could also result in increased demand as businesses 
turn to OTs for help in devising ways to accommodate the 
disabled. On the other hand, demand for OT services in 
nursing homes could decline if efforts to weaken the 
National Nursing Home Reform act succeed. The Act 
currently calls for as much restraint-free care as possible. 
This requires evaluation by an OT to identify and help 
maintain an individual's capabilities. If the Act were 
weakened or massive exemptions were made, greater use 
of restraints would again be allowed resulting in less need 
of OT services. 

An issue that may not affect demand, but may affect 
whether the demand is met is a 1984 Medicare regulation 
limiting the rate at which OTs working as independent 
contractors can increase their rates. Because the rate has 
never been increased, Medicare reimbursement to OT- 
contrators has apparently lagged behind that of other 
insurers. As a result, OT-contractors may tend to favor 
facilities not heavily reliant on Medicare. Nursing homes, 
which often use contractors to provide legislatively 
mandated services, may suffer the most from this 
regulation where Medicare is often a major source of 
funding. 



References 

1. Silvestri G, Lukasiewicz J. Occupational employment 

projections. Monthly Labor Review. November 1991. 

2. Kreml BB. Survey of Human Resources-1991. Chicago, IL: 

American Hospital Association; 1992. 

3. Office of Employment Projections. Unpublished data 

from the OES Occupation/Industry Staffing Matrix. 
Washington, DC: U.S. Department of Labor, Bureau of 
Labor Statistics; 1991. 

4. Office of Employment and Unemployment Statistics. 

Unpublished data from the Current Population 
Survey. Washington, DC: U.S. Department of Labor, 
Bureau of Labor Statistics; 1992. 

5. Committee on Allied Health Education and 

Accreditation. Allied Health Education Directory: 13th 
and 20 Editions. Chicago, IL: American Medical 
Association; 1985 and 1992). 

6. Bureau of Labor Statistics. Total and Net Occupational 

Separations: A Report on Recent Research. Washington, 
D.C.: U.S. Department of Labor; August 1991. 



80 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Speech-Language Pathologists and Audiologists 



Although they are separate and distinct occupations, 
speech-language pathologists and audiologists are closely 
related in that they both address communications 
disorders. As a result, data for the two often are 
combined. The Bureau of Labor Statistics' (BLS) Current 
Population Survey (CPS) estimates that 79,000 individuals 
were employed in these two occupations in 1992. 1 At the 
same time, the American Speech-Language, Hearing 
Association (ASHA) had a membership of 65,660, the 
overwhelming majority of whom held a master's degree or 
above. ASHA also estimated that when including 
nonmembers, essentially those with only a baccalaureate, 
the total supply of these occupations approached 131,300. 

The BLS expects the two occupations combined to grow 
34 percent between 1990 and 2005, faster than the 20 
percent growth projected for all occupations. The mini- 
baby boom should contribute to demand for speech 
pathologists because roughly 70 percent of this 
occupation's caseload is younger than 18. Driving demand 
for audiologists will be the growing number of elderly, 
especially those over 75, who suffer from hearing 
problems. 2 

Issues 

Three issues face the speech and hearing professions. 
The first is whether the economic demand for these 
occupations exceeds supply. Evidence supporting an 
excess of demand includes an increase in the hospital 
vacancy rate for speech pathologists from 9.9 percent in 
1989 to 11.1 percent in 1991 (vacancy rates for audiologists 
were not collected.) 3 In addition, ASHA recorded vacancy 
rates in schools of between 7 and 8 percent. Prior to this, 
there were enrollment declines in both speech and hearing 
programs during much of the 1980's. Meanwhile demand 
for full-time-equivalent employment in hospitals increased 
56 percent between 1983 and 1990. 4 Enrollments have 
since turned around, however, and higher- than-aver age 
salary growth suggests that market forces are working to 
increase supply. 



In addition, there also is a question of whether the 
actual need for services is being adequately converted into 
economic demand. One study has shown that while 20 
percent of the speech-language impaired were over 65, 
they represented only 10 percent of the case load for 
speech pathologists, and while 43 percent of the hearing- 
impaired population was over 65, it represented only 24 
percent of the case load for audiologists. 5 At least part of 
the disparity between need and demand for audiologists 
appears related to Medicare regulations limiting 
reimbursement to specific services. As a result, ASHA is 
developing legislation seeking expanded reimbursement. 
In the meantime, Medicare coverage has become even less 
adequate as interventions that were not even conceived of 
when Medicare was written have become available. 
Examples include new augmentative equipment, devices, 
and techniques that help treat the hearing and 
communications problems caused by neurological deficits 
or dementia. 

The final issue is whether services mandated for school- 
aged children are being provided. Federal law (PL. 94- 
142) guarantees that handicapped children up to age 21 are 
to receive whatever speech and hearing therapy is needed 
to enable them to learn. A Department of Education report 
to Congress, however, reported that a shortage of qualified 
individuals continues to impede the delivery of services 
and that speech and language therapists are among those 
needed most. 6 Anecdotal evidence suggests that many 
jurisdictions lack the resources to fund services. 



2993 • Health Personnel in the United States • Ninth Report to Congress • 81 



References 

1. Office of Employment and Unemployment Statistics. 

Employment and Earnings. Washington, DC: U.S. 
Department of Labor, Bureau of Labor Statistics; 
January 1993. 

2. Bureau of Labor Statistics. Occupational Outlook 

Handbook, 1992-93. Washington, D.C.: U.S. Department 
of Labor; May 1992. Bulletin 2400. 

3. Kreml BB. Survey of Human Resources-1991. Chicago, IL: 

American Hospital Association; 1992. 

4. American Hospital Association. Unpublished U.S. 

Registered Community Hospitals data. Chicago, IL; 
Annually, 1983 to 1990. 

5. Fein DJ. Projections of Speech and Hearing Impairments to 

2050. Rockville MD: American Speech-Language 
Hearing Association; 25(11); 31. 

6. Office of Special Education Programs. To Assure the Free 

Appropriate Public Education of all Children with 
Disabilities, Fourteenth Annual Report to Congress on the 
Implementation of the Individuals with Disabilities 
Education Act. Washington, D.C.: U.S. Department of 
Education; 1992. 



82 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Respiratory Therapy Personnel 



The Bureau of Labor Statistics (BLS) estimated that 
respiratory therapists held about 60,000 jobs in 1990, a 
number projected to grow 52 percent by 2005. ' Also in 
1990 the American Hospital Association estimated that 
there were 63,285 full-time equivalent respiratory therapy 
personnel employed in hospitals: 39,907 therapists and 
23,378 respiratory therapy technicians. 

Driving the rapid projected growth for this occupation 
is the expansion of the middle-aged and elderly 
population, which is more likely to suffer from such 
diseases as pneumonia, chronic bronchitis, emphysema, 
and heart disease. The growing number of AIDS patients, 
who often suffer from lung disease, and the reemergence 
of TB also will contribute to demand. Advances in 
technology are expected to increase demand as well by 
making additional services available. 

The method of updating its educational requirements is 
a unique characteristic of this occupation. Using a needs- 
based approach, respiratory therapists have effectively 
eliminated the criticism other professions face when 
educational requirements are updated without any 
systematic means of determining the needs of employers. 
The respiratory therapists' system works by surveying 
both workers and employers to identify current needs and 
skills. The findings are then shared with educational 
programs for purposes of updating their curriculum, and 
are eventually incorporated into the registry exam. The 
system thus avoids unwarranted educational requirements 
while retaining the flexibility to adapt to changing needs 
and advances. 2 

Issues 

The adequacy of supply of respiratory therapy 
personnel became a concern during the early to mid-1 980's 
when the number of graduates from both therapists and 
technician programs declined. 

Since 1988, however, the number of graduates and 
enrollments have increased. In 1992, there were a record 
8,817 graduates, 68 percent above the all time low recorded 



Figure 18 

Enrollments in RT and RTT Programs 



9000 



7000 



5000 



3000 




j i i i i i i i i 



1984 1985 1986 1987 1988 1989 1990 1991 1992 
Year 

i RTTs ohb RTs 

Source: AMA's Committee on Allied Health Education and Accreditation 



Figure 19 

Graduates of RT and RTT Programs 



5000 



4000 



3000 



2000 




j i_ 



j | L 



1984 1985 1986 1987 1988 1989 1990 1991 1992 
Year 

Source: AMA's Committee on Allied Health Education and Accreditation 



1993 • Health Personnel in the United States • Ninth Report to Congress • 83 



in 1987. Not surprisingly, the increase has coincided with 
a decline in the American Hospital Association's calculated 
hospital vacancy rates: from 8.9 percent in 1989 to 7.4 
percent 1991. 3 This drop is particularly revealing in that 
90 percent of respiratory therapy personnel are employed 
in hospitals. 4 Data from the American Association of 
Respiratory Care showed similar trends, with full-time- 
equivalent vacancy rates declining from 5.3 percent in 1987 
to 4.8 percent in 1992. 5 

One of the primary issues for this occupation is lack of 
specific Medicare reimbursement for respiratory therapy 
services. In hospitals, reimbursement must come from a 
general "room and board" Medicare rate, for which there 
is competition from other ancillary services. Elsewhere, 
reimbursement is limited to services provided at skilled 
nursing facilities (SNFs), and then only for services 
provided by a therapist who is employed by a hospital 
with official ties to the SNF Similarly, reimbursement for 
services in a home health care environment are available 
only to the extent that they can be collected under charges 
for equipment. The AARC claims such limited 
reimbursement inhibits access and affects care. They 
therefore advocate for specific Medicare reimbursement 
for services provided in hospitals, nursing homes, and 
home health care. While expanding coverage could 
improve access, however, it also would increase costs. 
The subject of expanded reimbursement warrants further 
analysis. 



References 

1. Silvestri G, Lukasiewicz J. Occupational employment 

projections. Monthly Labor Review. November 1991. 

2. Joint Review Committee for Respiratory Therapy. 

Interview with Philip A. von der Heydt, Executive 
Director. Euless TX; Jan. 22, 1993. 

3. Kreml BB. Survey of Human Resources-1991. Chicago, IL: 

American Hospital Association; 1992. 

4. Office of Employment Projections. Unpublished data 

from the OES Occupation /Industry Staffing Matrix. 
Washington, DC: U.S. Department of Labor, Bureau of 
Labor Statistics; 1991. 

5. Task Force on Professional Direction. A Study of 

Respiratory Care Human Resources in Hospitals 1992. 
Dallas, TX: American Association for Respiratory 
Care; 1992, p. 3. 



84 • Health Personnel in the United States • Ninth Report to Congress • 2993 



Dietitians 



In 1993 the American Dietetic Association (ADA) 
estimated that about 80 percent or 43,600 out of an 
estimated 54,478 registered dietitians were employed in 
dietetics. 1 The Bureau of Labor Statistics (BLS) estimates 
show that dietitians and nutritionists held about 45,000 
jobs in 1990. 2 The ADA's 1993 estimate is slightly lower 
than BLS's 1990 estimate partly because the ADA's count is 
of those holding the Registered Dietitian (RD) credential 
awarded by its Commission on Dietetic Registration. The 
BLS, on the other hand, is indifferent to credentials and 
accepts the count of any employer reporting a "dietitian or 
nutritionist" on staff. 

The BLS projects that jobs for dietitians and 
nutritionists will grow about 24 percent between 1990 and 
2005, about average for the total workforce. 2 Factors 
creating the demand include general population growth, 
heightened interest in nutrition, and the willingness of 
individuals to pay out-of-pocket for services. While 
hospitals employed the largest share of wage and salary 
dietitians, about 39 percent in 1990, their share is expected 
to decline to about 34 percent in 2005 as employment 
increases in nursing homes and other residential care 
facilities such as halfway houses. As a group, State and 
local governments should remain the third largest 
employer of dietitians. Analysis of factors commonly used 
to identify shortages suggests that the supply of dietitians 
is adequate to meet current demand. 



As with many other occupations, the future role 
dietitians play in the changing health care system will 
largely be determined by the extent to which they are 
reimbursed. Currently, consumers pay directly for many 
dietetic services. Medicare payment for hospital services is 
through a general room-and-board rate for which dietetic 
and ancillary services must compete. The ADA argues 
that lack of reimbursement limits access and quality of 
care and contributes to increased costs because good 
nutrition prevents disease and speeds recovery. 

While there is substantial data documenting the costs of 
diet-related illnesses, there is little if any data 
demonstrating the efficacy of expanded services. More 
research is needed to validate claims that professional 
dietetic services are cost-effective and that investing in 
those services save money by preventing illness and 
hastening recovery. 

References 

1. Education Department. Statement from Beverly 

Mitchell. American Dietetic Association; Feb. 9, 1993. 

2. Silvestri G, Lukasiewicz J. Occupational employment 

projections. Monthly Labor Review. November 1991. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 85 



86 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Diagnostic Imaging and Ionizing Therapy Personnel 



Radiologic technologists and technicians, nuclear 
medicine technologists, sonographers, magnetic resonance 
technologists, and radiation therapists compose a group of 
occupations collectively involved in either diagnostic 
imaging or ionizing therapy. According to the Bureau of 
Labor Statistics' (BLS), there were about 10,400 nuclear 
medicine technologists and about 149,000 individuals 
employed as radiologic technicians and technologists, 
radiation therapists, sonographers, or magnetic resonance 
technologists in 1990. 1 Other than membership data from 
professional associations, which typically do not represent 
an entire profession, there are no other supply estimates. 
As a result, it is impossible to determine the absolute or 
relative growth of any occupation other than nuclear 
medicine technologists. 

Issues 

The lack of reliable, occupational specific supply data 
inhibits a thorough analysis of claims, such as those made 
in 1989 by the American Healthcare Radiology 
Administrators and others, that a shortage of these 
personnel exist. 2 American Hospital Association (AHA) 



Figure 20a 


Graduates of Nuclear Medicine, 


Radiation Therapy and Sonography Programs 


1000 
800 
600 




























^^ 
























IflgggP^ 










400 
















*^ 








200 






"T 


















82-83 83-84 84-85 85-86 86-87 87-88 88-89 89-90 90-91 91-92 


Year 


Therapy Medicine 


Source: AMA's Committee on Allied Health Education and Accreditation 



data show that between 1989 and 1991 the vacancy rates 
for sonographers and radiologic technologists declined by 
about 1 percentage point each to about 7 percent, the level 
used by the AHA to characterize a shortage. 3 Over the 
same time, the AHA vacancy rate for radiation therapy 
technologists grew from 10.3 percent to 12.9 percent while 
the rate for nuclear medicine technologists remained 
unchanged at about 8.9 percent. 

The hospital vacancy rate for nuclear medicine 
technologists could be considered a good proxy for the 
occupation's overall vacancy rate since about 92 percent of 
the occupation is employed in hospitals. 4 Nuclear 
medicine is a relatively small occupation, however, making 
it relatively easy to incur large vacancy rates with only a 
few vacancies. Because only about 58 percent of the 
remaining occupations are employed in hospitals, and 
because there are no occupational-specific estimates of 
their proportion in hospitals, the use of AHA vacancy rate 
data as an overall proxy for vacancies is not advisable. 





Figure 20b 

Graduates of Radiographer Programs 




9500 
9000 
8500 
8000 
7500 
7000 
6500 
6000 




















































































X 


•" 


-\ 










M 
9 


















J 


' 


















































5500 


82-83 

Source: A 


83-84 84-85 


85-86 86-87 87-88 88-89 89-90 90-91 91-92 
Year 




i 


MAs Committee o 


n Allied h 


earth Edi 


cation ar 


d Accred 


tation 









1993 • Health Personnel in the United States • Ninth Report to Congress • 87 



Higher-than-average salary increases often follow any 
unresolved personnel shortages. Data shows that earnings 
for the general category of radiologic technicians and 
technologists increased 48 percent between 1983 and 1991; 
a rate faster than the 37 percent increase for all 
occupations, but slower than the 61 percent increase for 
the therapy occupations generally acknowledged to be in 
short supply. 5 

While the limited data available suggest a shortage of 
some, if not all, of the occupations in this group, it is 
encouraging to note that graduates of accredited 
educational programs in radiography, radiation therapy, 
and nuclear medicine have shown rapid growth after 
experiencing declines during the mid-1980's. Only the 
relatively young sonography occupation showed steady 
growth through the 1980's. 

The licensing of radiologic personnel continues to be an 
issue. The American Society of Radiologic Technologists 
(ASRT) maintains that licensure laws would guarantee an 
appropriately trained workforce that would reduce cost 
and unnecessary exposure to radiation by decreasing the 
need to repeat procedures. Congress in 1981 passed the 
Consumer-Patient Radiation Health and Safety Act which 
provided for the development of standards for accrediting 
educational programs and for certifying individuals. The 
Act, however, preserved the States' right to approve 
educational programs and regulate personnel. Since its 
passage, the States have adopted a slow, evolutionary 
approach to adopting licensure. As of June 1992, 29 States 
licensed radiographers, 22 States licensed radiation 
therapy technologists, and 15 States licensed nuclear 
medicine technologists. 



References 

1. Silvestri G, Lukasiewicz J. Occupational employment 

projections. Monthly Labor Review. November 1991. 

2. Hanwell LL. Summit on Manpower Report, April, 1989. 

American Health Care Radiologic Administrators; 
April, 1989. 

3. Kreml BB. Survey of Human Resources-1991. Chicago, IL: 

American Hospital Association; 1992. 

4. Office of Employment Projections. Unpublished data 

from the OES Occupation /Industry Staffing Matrix. 
Washington, D.C.: U.S. Department of Labor, Bureau 
of Labor Statistics; 1991. 

5. Office of Employment and Unemployment Statistics. 

Unpublished data from the Current Population 
Survey. Washington, D.C.: U.S. Department of Labor, 
Bureau of Labor Statistics; 1992. 



88 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Medical Records Personnel 



Medical records technicians (MRTs) held 52,000 jobs in 
1990, a number projected to grow 54 percent to 80,000 jobs 
by 2005. 1 Driving this growth is the increasing number of 
tests, procedures, and services that need to be recorded for 
use by third-party payers, providers, and patients to 
answer questions about reimbursement, quality assurance, 
and risk management. 

Issues 

The current availability of jobs and rapid projected 
growth might suggest that a shortage of medical records 
personnel exists. 2 The limited data that currently exists, 
however, fails to support such a claim. American Hospital 
Association (AHA) vacancy rates for the two occupations 
responsible for maintaining hospital records— medical 
record coders and medical transcriptionists — were 6.5 
percent and 5.7, respectively, in 1992, below the 7 percent 
rate used by the AHA to characterize a shortage. 3 The 
usefulness of AHA data, however, is limited because 
hospitals only employ about 58 percent of this occupation. 4 
Nonetheless, the limited earnings data available shows 
that wages have experienced only average or slightly 
higher-than-average growth over the last three years, a fact 
that is not indicative of an occupation in short supply. 572 
Also, employment grew 24 percent between 1983 and 1992, 
only slightly faster than the 17 percent growth in total 
employment. 5 

The likelihood of a future shortage is difficult to 
analyze because of problems in projecting supply. 
Currently two levels of certification for this occupation are 
available; a two-year Accredited Record Technician (ART) 
credential, and a 4-year Registered Record Technician 
(RRT). While employers reportedly prefer hiring formally 
educated and credentialed individuals, there are no laws 
requiring them to do so. As a result, fully half of all 
positions are filled by individuals having less education 
than the amount needed to acquire the two-year associate 
degree. 5 Graduate data is therefore not useful in estimating 
supply. Nonetheless, it is interesting to note that between 
1986 and 1992 enrollments in the two-year programs 
increased 79 percent while the number of graduates 



increased 30 percent. 6 Growth was not as great in the four- 
year programs where enrollments increased 24 percent and 
the number of graduates actually declined by 18 percent. 6 

As the result of an Institute of Medicine study calling 
for the development of computer-based record keeping, 
the American Health Information Management 
Association (AHIMA), hospitals, physicians, insurers, and 
other organizations have joined to establish the Computer- 
Based Patient Record Institute (CPRI). 7 The institute is 
attempting to develop a universally accepted, 
longitudinal, standardized, computer-based record 
keeping system capable of meeting all clinical, financial, 
and research needs. Such a system would theoretically 
reduce costs by allowing patient records to be 
electronically entered, filed, and transmitted to insurers 
and other involved parties, thereby eliminating the need 
for many of the clerical workers currently involved in the 
copying and filing of paper documents. The effect of such 
a system on the occupation is unknown. In theory, health 
care providers would learn to directly input data 
themselves. 

Developing such a system is an enormous task that will 
take time. Goals that need accomplishing, include the 
development of a standardized coding for drugs, diseases, 
and personal identification; and the development of 
policies and mechanisms that will insure patient 
confidentiality, and a legal framework that will facilitate 
the proper use of computer-based patient records. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 89 



References 

1. Silvestri G, Lukasiewicz J. Occupational employment 

projections. Monthly Labor Review. November 1991. 

2. Amatayakul M. Results of the 1992 manpower survey. 

Journal of the American Health Information Management 
Association. December, 1993;63:101-106. 

3. Kreml BB. Survey of human resources-1991. Chicago, IL: 

American Hospital Association; 1992. 

4. Office of Employment Projections. Unpublished data 

from the OES Occupation /Industry Staffing Matrix. 
Washington, DC: U.S. Department of Labor, Bureau of 
Labor Statistics; 1991. 

5. Office of Employment and Unemployment Statistics. 

Unpublished data from the Current Population 
Survey. Washington, DC: U.S. Department of Labor, 
Bureau of Labor Statistics; 1992. 

6. Committee on Allied Health Education and 

Accreditation. Allied Health Education Directory. 
Chicago, IL: American Medical Association; select 
years. 

7. Institute of Medicine. The computer based patient record: an 

essential technology for health care. Washington, D.C.: 
National Academy of Sciences; 1991. 



90 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Clinical Laboratory Personnel 



Clinical laboratory personnel are composed of a 
number of occupations, including medical technologists, 
medical laboratory technicians, cytotechnologists, and 
histologists. Each of these has educational requirements 
that range from on-the-job training to a baccalaureate. 

The Bureau of Labor Statistics' Current Population 
Survey (CPS) found 301,000 persons employed as clinical 
laboratory technicians and technologists in 1992, an 18 
percent increase since 1983, about the same as the 17 
percent growth in total employment. 1 Unfortunately, 
occupational specific employment data for the 
occupational components of the clinical laboratory field 
are only available from the professional associations 
whose membership is limited. 

Issues 

While those employed in the clinical lab field 
overwhelmingly believe that a personnel shortage exists, 
the claim for one is based largely on widely varying 
vacancy rate data and anecdotal evidence. In 1991, for 
instance, the American Hospital Association (AHA) 
identified only one clinical lab occupation as having a 
vacancy rate over the 7 percent it uses to characterize a 
shortage (cytotechnologists, 12.8 percent). 2 In contrast, 
hospital vacancy rate data collected by the American 
Society of Clinical Pathologists (ASCP) for 1992 depicted 
double digit vacancy rates for all but one occupation. 3 It 
should be noted, however, that the ASCP's sample size 
and response rate were less than that of the AHA's, and 
that a survey's timing can also affect the results. A survey 
conducted shortly before the end of a school year can yield 
a different outcome than one conducted a month after. 
Also considered an indicator of shortages is the length of 
time needed to recruit personnel. AHA data identifies 
cytotechnologists as one of the hardest occupations to 
recruit with about 42 percent of hospitals reporting that 
they need more than 90 days to fill a position. 2 An analysis 
of AHA data also indicates that the remaining three 
occupations are generally easier to recruit— taking less 
time than the average for all occupations. 



Also conflicting with the profession's feeling that a 
shortage exists, is BLS historical data depicting 
employment and salaries for all clinical lab workers as 
growing at a rate about equal to that of all occupations as a 
whole. 1 /4/5 Average, rather than rapid growth in these 
areas would seem to argue against the existence of a 
shortage, even though a shortage does appear to exist in 
cytotechnology. Although educational programs, 
enrollments, and graduates from accredited programs 
started to decline in the mid-1980s, it is encouraging to 
report that enrollments and graduates are again on the 
increase. 

In addition to the shortage issue are Congressional 
concerns over the quality of testing and the access of rural 
and underserved populations to qualified medical 



Figure 21 

Enrollments and Graduates of 
Clinical Laboratory Programs 



15000 



12000 



9000 



6000 



3000 




1986 1987 1988 1S 
Year 



Source: AMA's Committee on Allied Health Education and Accreditation 



1990 1991 

■■■» Graduates 



2993 • Health Personnel in the United States • Ninth Report to Congress • 91 



laboratory services. As a result, the Bureau of Health 
Professions was instructed to conduct a study of clinical 
laboratory personnel to identify factors affecting supply in 
rural and underserved areas and to identify alternative 
routes for the certification of clinical laboratory personnel. 
Results are pending. 

Another issue or concern is over the effects that the 
Clinical Laboratory Improvement Amendments (CLIA) of 
1988 will have on clinical laboratory personnel. Based on 
such factors as complexity, danger to the patient, and risk 
of error, the Amendments now divide clinical laboratory 
tests into three categories— complex, moderate, and 
waivered. The Act also specifies educational standards for 
managers and personnel performing tests at each of these 
three levels. It is the latter that has created considerable 
debate over the effect CLIA will have on rural labs: 
facilities that often employ experienced individuals who 
are adequately prepared but lack formal education. 
Because of these concerns, the Center for Disease Control's 
National Advisory Committee is proposing that existing 
laboratory personnel be grandfathered in. 

Technological improvements promise to bring rapid 
change to the field of clinical laboratory science. While 
some tests will become less complex and less labor- 
intensive, newer and more complex tests requiring greater 
levels of education will also be developed. In many 
respects, clinical laboratory science is analogous to the 
computer field where technological change has grown by 
leaps and bounds. As a result, it is difficult to estimate 
technology's effect on overall demand for labor, although 
educational requirements are likely to increase. 

The appropriate level of education needed to work in a 
clinical laboratory continues to be an issue. The 
proceedings from a special panel on clinical laboratory 
workers found that "...it is difficult to definitively agree 
upon what level of training is required for different jobs — 
both currently and in the future."6/ This uncertainty over 
the appropriate level of training is compounded by 
disagreement over the roles some workers play, the fact 
that only a few States license clinical laboratory personnel, 



and that while certification is offered by a number of 
organizations, it is not required. While the general 
consensus is that not every worker requires a 
baccalaureate or extensive training, there appears to be 
agreement that medical technologists, cytotechnologists, 
and others who will perform complex tests should be 
required to pass minimal educational and competency 
requirements. For occupations such as medical lab 
technicians, who perform more simple tests, such 
requirements appear to be unnecessary. Still in question 
are what requirements are needed of those performing 
moderately complex tests. CLIA regulations currently 
permit high school graduates trained on the job to perform 
moderately complex testing, which is estimated to be 
about 75 percent of all lab testing.6/ 

Finally, AIDS and the reemergence of TB promise to 
increase the demand for laboratory tests. The degree to 
which demand will increase, however, is unknown. 

References 

1. Bureau of Labor Statistics. Employment and Earnings. 

Washington, DC: U.S. Department of Labor; January 
1993. 

2. Kreml BB. Survey of Human Resources-1991. Chicago, IL: 

American Hospital Association; 1992. 

3. Castleberry BM. 1992 Wages and vacancy survey of U.S. 

medical laboratory positions: part 2. Laboratory 
Medicine. February 1993; Vol. 24, No. 2. 

4. Bureau of Labor Statistics, Employment and Earnings. 

Washington, DC: U.S. Department of Labor; January 
issues from selected years. 

5. Office of Employment and Unemployment Statistics. 

Unpublished data from the Current Population 
Survey. Washington, DC: U.S. Department of Labor, 
Bureau of Labor Statistics; 1992. 

6. Rubin R, Mendelson D, Ford J. Proceedings from the 

Lewin-VHI panel on clinical laboratory personnel. Vienna, 
VA: Lewin-VHI; April 1993; p 18.t 



92 • Health Personnel in the United States • Ninth Report to Congress • 2993 



Public Health 



Stephen Tise, Office of Health Professions Analysis and Research, BHPr. 



The Institute of Medicine (IOM) in The Future of Public 
Health defined public health's mission as assuring the 
conditions for people to be healthy. 1 Although often 
thought of as a provider of last resort, public health's 
primary focus is not the provision of individual care, but 
community disease prevention and health promotion. 

While a comprehensive and diverse number of services 
and entities are involved in insuring the public's health, 
the IOM recommends that government agencies take 
primary responsibility for three core functions. These core 
functions and their components include: 

■ Assessment— the collection of data, monitoring of 
disease incidence, and the monitoring of health outcomes. 

■ Policy Development— the development of sound 
health policy and planning through the use of public 
health's scientific skills and knowledge. 

■ Assurance— the prevention of epidemics; protection 
of the environment, workplaces, housing, food, and water; 
responding to disaster related health problems; assuring 
the availability of quality medical care; providing medical 
care when needed; and securing a skilled public health 
workforce. 

Performing these functions requires the work of a 
variety of public health professionals, including physicians 
(many of whom are board-certified in preventive 
medicine), nurses, dentists, epidemiologists, 
environmental health personnel, industrial hygienists, 
health service administrators, nutritionists, social workers, 
and educators. There are currently no national 
examinations or licensure requirements for public health 
practice; furthermore, there is no strictly defined scope of 
practice other than the goal of protecting and improving 
the population's health and well-being. As a result, 
educational requirements for practice in this diverse field 
are varied. A generally recognized set of core public 
health disciplines, however, includes biostatistics, 
environmental sciences, epidemiology, health behavior, 
and health care policy, administration, and organization. 2 



The supply of public health professionals is impossible 
to estimate accurately, due in part to some disagreement 
over which occupations compose public health and their 
lack of specific educational, competency, or licensure 
requirements. Estimating supply, therefore, is limited to 
the opinions of experts in the field. Most experts would 
agree that there is a shortage of adequately trained 
individuals, especially in such expanding fields as 
environmental health. 

Issues 

Effects of the changing health care delivery system are 
the principle challenges confronting public health. 
Expansion of insurance coverage and greater reliance on 
managed care both could fundamentally alter the public 
health infrastructure. Health maintenance organizations, 
for instance, might hire their own epidemiologists to 
assess disease prevalence and devise prevention strategies 
for their members. 

An increased focus on health maintenance and disease 
prevention in the private and public sectors might result in 
more community-wide primary health care programs. 
Currently, public health programs tend to emphasize 
specific populations, such as minority and economically 
disadvantaged groups and specific health conditions such 
as diabetes. 2 Critics complain that the needs of individuals 
who fall outside these narrowly defined groups are not 
being met. 

The evolving health care financing and delivery 
systems also create concerns. Because of its history as a 
service provider, those in public health are concerned that 
interest in public health agencies may decline if health 
insurance coverage increases, and health maintenance 
organizations become more accountable for the health of 
their members. At risk are these agencies' other important 
functions of assessment and policy development, which 
might be neglected. 



2993 • Health Personnel in the United States • Ninth Report to Congress • 93 



Nonetheless, experience has shown that financing 
alone does not guarantee access to appropriate health care 
services. Cultural and physical barriers, such as historical 
reliance on alternative forms of medicine and difficulty in 
finding transportation, are also major problems for those 
needing access to health care services. As part of its 
assurance function, therefore, public health must be able 
to develop and administer community-based outreach 
programs to insure true access to all. 

Aside from the opportunities and concerns associated 
with the changing health care financing and delivery 
systems, other issues requiring attention include the rapid 
expansion of areas such as environmental and 
occupational health, and accident and injury prevention. 
Previous versions of this report to Congress have 
highlighted the concerns that public health must find 
ways to address pollution, hazardous waste disposal, toxic 
exposures in the workplace, substance abuse and the 
Country's epidemic of violence. 3 The public health field 
must continue to recognize these areas as part of public 
health and move to address these problems. 

The final issue pertains to assuring an appropriately 
trained supply of public health professionals. Currently, 
the Master of Public Health (MPH) and Master of Science 
in Public Health (MSPH) degrees are regarded as public 
health's basic professional degrees. Twenty-six accredited 
schools of public health, 7 accredited health education 
programs, and 11 community medicine programs award 
them as well as an additional 69 nonaccredited 
programs. 1/2/4 More than 300 nonaccredited programs 
offer related degrees in areas such as health administration 
and education, and environmental health. 172 Accredited 
programs appear to provide the widest educational base 
in public health by requiring completion of courses in five 
specific areas. 



The Pew Commission has recommended that public 
health's mission of health promotion and disease 
prevention be more strongly linked to educational 
requirements. It also recommends development of model 
collaborations between schools of public health and local 
and State health departments in an effort to match 
academic training with real world needs. Further, it 
suggests public health schools work together to develop 
new, innovative approaches, including continuing 
education courses. Finally, the Pew Commission 
recommends that public health programs assist other 
clinically-oriented health professions to better understand 
the needs of the public and community through 
collaborative educational programs. 

References 

1. Division of Health Care Services. The Future of Public 

Health Washington, DC: Institute of Medicine; 1988. 

2. O'Neil EH. Health Professions Education for the Future: 

Schools in Service to the Nation. San Francisco, CA: Pew 
Health Professions Commission; 1993. 

3. Bureau of Health Professions. Health Personnel in the 

United States: Eighth Report to Congress. Washington, 
D.C.: U.S. Department of Health and Human Services; 
1991. 

4. Association of Schools of Public Health, Statements from 

Research Department Personnel. Washington, D.C.: 
June 29, 1993. 



94 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Pharmacists 



Stephen Tise, Office of Health Professions Analysis and Research, BHPr. 



The Bureau of Labor Statistics (BLS) estimated that 
there were about 171,000 pharmacists in 1990. ' This is 
comparable to a recent census of pharmacists which 
estimated that there were about 172,000 pharmacists 
actively employed in 1992. 2 According to data from the 
BLS, employment of pharmacists grew 8 percent between 
1983 and 1990. 1 

Issues 

As with many other health care occupations, there has 
been concern about the adequacy of the nation's supply of 
pharmacists to meet current and future demand. Despite 
years of having a practitioner-to-population ratio of about 
64 pharmacists for every 100,000 people, evidence 
commonly associated with shortages suggests that the 
demand for pharmacists in the recent past may have 
exceeded supply. The evidence includes higher-than- 
average growth in earnings, hospital vacancy rates which 
the AHA characterizes as representing a shortage, and 
reports from educators, who monitor the employment 
activities of recent graduates, that demand for their 
graduates is exceeding supply. 

Factors possibly contributing to the need for more 
pharmacists include the growing population; increased use 
of prescription drugs, especially among the growing aged 
population; and, pharmacy's expanding role under recent 
Medicaid regulations requiring review of patient drug use 
and patient counseling. Fortunately, as the following graph 
shows, enrollments and graduates have been increasing 
since the mid-1980s after several years of decline. In 
addition, the American Hospital Association's (AHA) most 
recent human resources survey shows a decline in the 
vacancy rate for pharmacists to just below the 7 percent 
rate it considers a shortage. 3 Also helping to improve the 
balance between supply and demand is the growing 
number of pharmacy programs, an abundance of 
applicants, and a trend toward using more pharmacy 
technicians and robotics to help count and dispense drugs. 
As with many occupations, personnel shortages are likely 
to be local or regional rather than national in nature. 



Figure 22 

First-Year Enrollments and Graduates 
of Schools of Pharmacy 



10000 
9000 
8000 
7000 
6000 
5000 
4000 




j i i i i i i i i i i i i i i i 



76 77 78 79 '80 '81 '82 '83 '84 '85 '86 '87 '88 '89 '90 '91 
Year 

First-Year Students «■■■■» Graduates 

Source: American Association of Colleges of Pharmacy 



An educational issue confronting the profession is the 
American Council of Pharmaceutical Education's intent to 
create a single, degree for all pharmacists. Currently, 
students can obtain a bachelor's degree in pharmacy in 
five years and a doctorate in six. The Council would 
eliminate the five-year option. Proponents argue that 
additional education is needed to prepare pharmacists for 
their expanding role in patient counseling, drug 
monitoring, and clinical services. Opponents question the 
need for doctoral level pharmacists in many employment 
settings and fear the extra year of schooling will not only 
increase educational but overall health care costs. At the 
time of this report, the proposal was going through a 
comment and hearing phase. The official adoption of the 
doctorate degree for all pharmacists is not expected to 
occur before 2000, making estimates of costs and effect on 
supply difficult to calculate. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 95 



No matter whether they graduated from five- or six- 
year programs, the role of pharmacists is becoming more 
consumer-oriented. The 1990 Omnibus Budget 
Reconciliation Act (OBRA) requires State Medicaid 
programs to implement drug use review programs and 
requires pharmacists to offer counseling to all Medicaid 
patients. The review program is intended to improve the 
quality of pharmaceutical care by ensuring prescriptions 
are appropriate, necessary, and unlikely to have adverse 
medical effects. The legislation left the decision of how to 
define "counseling" to each State; it may include 
instruction on proper dosage, duration of treatment, 
storage, what to do if a dose is missed, and how to identify 
common side effects. 

The cost and method of payment for these extra 
services is a concern to pharmacists, private insurance 
companies considering the same requirements, and 
members of the public. The Health Care Financing 
Administration (HCFA) has estimated that the time 
needed to review a patient's records, make an offer to 
counsel, and then provide counseling will take two to four 
minutes at a cost of $1 to $2 a prescription. 4 Several 
demonstration projects are under way to study issues of 
review, counseling, and compensation. One proposal to 
increase dispensing fees does not cover instances when a 
pharmacist provides counseling but not dispense a drug. 

The cost-conscious also have raised concerns that the 
cost of reviewing and counseling may exceed any realized 
savings. Several recent studies, however, show that review 
and counseling are cost-effective. 



References 

1. Bureau of Labor Statistics, Employment and Earnings. 

Washington, DC: U.S. Department of Labor; January 
issues. 

2. White W, Bedford D, Yamasaki A. 1991 Census of 

Pharmacists licensed in the United States (Draft). Vector 
Research, Inc.: November 4, 1991. 

3. Kreml BB. Survey of Human Resources-1991. Chicago, IL: 

American Hospital Association; 1992. 

4. Martin S. What you need to know about OBRA '90. 

American Pharmacy. January 1993; Vol. NS33, No. 1. 



96 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Optometrists 



Stephen Tise, Office of Health Professions Analysis and Research, BHPr. 



According to the American Optometric Association 
(AOA), about 27,600 full-time-equivalent optometrists 
were practicing in 1993.' The Bureau of Labor Statistics' 
(BLS) 1990 estimate of optometrists jobs was 37,000. 2 The 
difference may be partly explained by the Bureau's 
counting of both full- and part-time jobs and that many 
optometrists work in more than one location or job and 
would therefore be counted twice. 

The AOA estimates the active supply of optometrists 
will increase by about 1.9 percent annually from 25,900 in 
1990 to 31,000 in 2000. 1 This is faster than the 1.2 percent 
annual growth in new jobs that the BLS projects for the 
period 1990 to 2005. The BLS projection represents a 20 
percent job growth from 37,000 in 1990, to about 45,000 in 
2005. 2 





Figure 23 

Graduates of Optometry Programs 
1983-1992 


1300 

1200 

■a 

CO 
CD 

1100 






:||r 

I I I I I I I I I I 


1000 


1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 
Year 

Source: Association of Schools and Colleges of Optometry 



Issues 

Currently, supply and demand for optometrists appears 
to be in balance, although it requires monitoring. The 
AOAs successful and ongoing legislative activism 
continues to expand optometry's market through 
expansion of State practice acts. Since the early 1970's, 
when the practice of optometrists was limited to 
performing simple eye examinations for purposes of 
prescribing corrective lenses, all states have come to 
permit the field to use diagnostic drugs while 32 States 
permit optometrists to prescribe therapeutic drugs for a 
number of specific eye diseases. The Association plans to 
continue its legislative efforts to have the remaining 18 
States grant similar therapeutic dispensing privileges. A 
1987 change to Medicare regulations has also expanded 
the market potential for optometrists. Now defined as 
"physicians", optometrists are reimbursable for all 
Medicare-covered services that State law allows them to 
provide. As a result, optometrists are beginning to reclaim 
a share of the eye care services they lost to 
ophthalmologists following Medicare's introduction. 1 

A number of studies have shown that for routine eye 
care, the cost of optometry services is less than for 
ophthalmology services. 3 One of the most recent studies 
shows that optometrists charged an average of $19 less for 
a basket of predetermined services. 4 Thus, it is possible 
that changes both in Medicare and State scope-of-practice 
laws will reduce costs and improve access by transferring 
demand from more expensive ophthalmologists to less 
expensive and more plentiful optometrists. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 97 



References 

1. American Optometric Association. Statements from an 

interview with Farell Aron. Louis, MO: March 4, 1993. 

2. Silvestri G, Lukasiewicz J. Occupational Employment 

Projections. Monthly labor Review. November 1991. 

3. American Optometric Association. Optometry, The 

Primary Eye Care Profession, Report on Cost and 
Availability of Routine Eye Care. Alexandria, VA. 

4. Mordachai S. Comparison of examination fees and 

availability of routine vision care by optometrists and 
ophthalmologists. Public Health Reports. July-August 
1991;106;457. 



98 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Podiatrists 



Stephen Tise, Office of Health Professions Analysis and Research, BHPr. 



The Bureau of Labor Statistics (BLS) estimated that 
podiatrists held about 15,000 jobs in 1990 and projected the 
number to grow to 23,000 by 2005. ! This would represent a 
46 percent increase, a rate that is much faster than the 20 
percent rate projected for all occupations. The BLS 
estimate of 15,000 appears somewhat high, however, in 
that between 1960 and 1991 only 12,366 individuals had 
graduated from schools of podiatry. Part of the variation 
may be attributable to BLS's system of counting both full 
and part-time jobs, so that dual job holders would be 
counted twice. The American Podiatric Medical 
Association (APMA) estimated that there were about 
13,000 practicing podiatrists in 1993, probably a more 
accurate estimate of supply. 2 

The seven U.S. schools of podiatric medicine are 
located in Florida, California, New York, Ohio, 
Pennsylvania, Illinois, and Iowa. Enrollment in these 
schools has increased substantially in the last 3 years from 
595 in 1988-89 school year to 802 in 1992-93. Currently no 
new programs are planned. The APMA reports that 
graduates' demand for residency positions exceeds the 
available supply, although the gap is narrowing. The 
profession has recently moved to adopt a proposal that 
would require one year of post-graduate training for all 
podiatry school graduates. 






Issues 

With respect to foot care, podiatrists are considered 
physicians and receive the same reimbursement as do 
their allopathic and osteopathic counterparts. Podiatrists 
are aware, however, that the changing health care system 
may change the way they practice. With roughly 70 
percent of podiatrists in private practice, any movement 
toward managed care systems would tend to force 
podiatrists to form new alliances with manage care 
organizations. 

On the supply side, there are relatively few podiatrists 
and they are poorly distributed. Nearly 50 percent are 
employed in the seven States having podiatry programs. 273 
Meanwhile, the demand for foot care continues to grow, 
driven largely by the aging of the population. Currently, 
the elderly compose about two-thirds of the average 
podiatrist's caseload. Despite the growth in demand, and 
the maldistribution of podiatrists, however, the supply of 
podiatrists appears adequate. Certainly the ability of 
primary care physicians and orthopedists to substitute for 
podiatrists helps to absorb excess demand for foot care. 
With a 1990 median net income of $73,746, however, 
podiatrists are probably less costly than orthopedists or 
primary care physicians. 4 It therefore seems reasonable 
that a geographic redistribution of podiatrists could help 
reduce costs. The profession agrees that a redistribution is 
desirable, but questions remain about how to achieve this. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 99 



References 

1. Silvestri, G., Lukasiewicz, J. Occupational employment 

projections. Monthly labor Review. November 1991. 

2. Interview with John R. Carson, Director of 

Governmental Affairs, APMA. 

3. Department of Governmental Affairs. Podiatric Medicine: 

A Reference Point. Bethesda, MD: American Podiatric 
Medical Association. 

4. Bureau of Labor Statistics, Occupational Outlook 

Handbook: 1992-93. Washington D.C.; U.S. Department 
of Labor: May 1992. Bulletin 2400. 









100 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Chiropractors 



Stephen Tise, Office of Health Professions Analysis and Research, BHPr. 



As of 1990 there were an estimated 45,000 to 50,000 
licensed chiropractors. An analysis of factors commonly 
used to identify shortages indicates that the supply of 
chiropractors is adequate to meet the demand. A 1991 
survey by the American Chiropractic Association 
corroborates this with its finding that 87 percent of its 
chiropractic respondents felt there was either an adequate 
or oversupply of chiropractors in their area. 1 

Although all 50 States and the District of Columbia 
license chiropractors and the Federal government defines 
doctors of chiropractic as "physicians" under the 
Medicare, Medicaid and Federal Employees 
Compensation Acts, chiropractic continues to bear a 
certain stigma that a number of the chiropractic 
associations attribute to years of discrimination and 
restraint of trade at the hands of organized medicine. 2/3 

Creating some confusion about chiropractic is its 
history of having two branches. The more conservative 
"straight" chiropractors confine their care to locating and 
correcting problems of the spine. Their guidelines suggest 
that they alert their patients to any medical findings that 
fall outside their narrow scope of practice and allow the 
patient to consult with another provider, if they choose, 
while continuing chiropractic care. 4 Direct referrals are 
avoided because straight chiropractic guidelines state, 
"Professional referral requires authority and competence 
to acquire accurate information concerning matters within 
the scope and practice of the profession for which a 
referral is made." 4 Straight chiropractic is also notable for 
its use of a terms-of-acceptance document. This document 
defines for the patient the objectives, responsibilities, and 
limitations of chiropractic care, and the terms under which 
care will be provided. "The patient's acknowledgement of 
the terms allows the provider the ability to accept the 
patient for care and allows the patient the ability to make 
an informed choice to accept the care." 4 

Straight chiropractic is currently taught in 3 of the 17 



chiropractic schools in the United States. These programs 
are accredited by the Straight Chiropractic Academic 
Standards Association (SCASA) which, until recently, was 
recognized as an accrediting body by the U.S. Department 
of Education. Application to the Department for renewed 
recognition, however, was denied. As of late 1992, nine 
States and the District of Columbia accepted graduates of 
SCASA programs to sit for licensure. According to a 
survey by the Federation of Chiropractic Licensing Boards, 
at least four jurisdictions will drop eligibility of SCASA 
graduates to sit for licensure while another four will 
reevaluate their positions in light of the Department of 
Education's decision. 

Historically, the second chiropractic branch was 
populated largely, but not entirely, by "mixers", who 
combined traditional spinal manipulation with expanded 
duties and adjunct therapies. As this branch grew, it 
included training that allowed the diagnosis, prognosis, 
and treatment of problems amenable to chiropractic care 
while recognizing the need to be able to refer patients to 
other health professionals. 

This branch of chiropractic is currently taught in 14 of 
the 17 schools in the United States and are accredited by 
the Council On Chiropractic Education (CCE). An 
additional program has been established in Connecticut 
and is seeking certification with CCE while North Carolina 
is studying the feasibility of developing a program. The 
CCE is recognized by the U.S. Department of Education. 
Graduates of CCE programs are eligible to sit for licensure 
in all 50 States and the District of Columbia. 



2993 • Health Personnel in the United States • Ninth Report to Congress • 102 



Issues 

Although considered by Medicare to be physicians, 
Medicare reimbursement for chiropractic services is 
limited solely to the manipulation of the spine. Services 
such as X-rays or other clinical services are not 
reimbursable and must either be paid for with secondary 
insurance or out of pocket. Members of the chiropractic 
profession feels this represents a barrier to individuals 
who would prefer to see a chiropractor, but opt to see a 
physician because their services are more likely to be 
covered. 

Another issue is related to the possible effects of the 
evolving health care system on chiropractors. The vast 
majority of chiropractors are self-employed and managed 
care providers such as HMOs and PPOs have not been 
anxious to hire them. Should a more managed care 
approach evolve, chiropractors run the risk of being 
excluded from a growing share of the health care market. 



References 

1. American Chiropractic Association. American 

Chiropractic Association 1991 Annual Physician Survey 
and Statistical Study. Alexandria, VA: Association 
Research Group; November 1991. 

2. Vice President Chiropractic Affairs. Statements from 

Howard Balduc. American Chiropractic Association: 
Arlington, VA; February 9, 1993. 

3. Wilk v. the American Medical Association, 805 F2d 352 

(7th cir. 1990). 

4. Practice guidelines for straight chiropractic. Proceedings 

of the International Straight Chiropractic Conference. 
Chandler, AZ: World Chiropractic Alliance; 1992. 



102 • Health Personnel in the United States • Ninth Report to Congress • 2993 



Clinical Psychologists 

Stephen Tise, Office of Health Professions Analysis and Research, BHPr. 



Psychologists employed in the provision of mental 
health care generally require a doctorate and may be 
trained as clinical psychologists, counseling psychologists, 
or school psychologists. Institutions award either a Doctor 
of Philosophy (Ph.D.) or a Doctor of Psychology (Psy.D.) 
degree depending on the training programs' broad goals 
and institutional practices. Programs awarding the Ph.D 
generally train individuals for careers in research, teaching 
and practice; the Psy.D is usually awarded by schools 
emphasizing evaluations and the direct delivery of 
services. 

Between 1979-80 and 1989-90 the number of doctoral 
programs increased 54 percent, from 162 to 250. 
Meanwhile, the annual number of doctoral degrees 
awarded increased 41 percent, from 1,673 to 2,358. This 
trend is expected to continue. 

The proportion of female doctoral students — 62 
percent of 1989-90 enrollments — continues to grow. 
Minorities, however, remain underrepresented, despite 
efforts to recruit them. 

Reliable supply estimates for psychologists providing 
mental health care do not exist. The demand for 
psychologists is somewhat flexible in that other mental 
health professionals provide similar services and can 
substitute for them. Some of the occupations capable of 
substitution include psychiatrists, psychiatric nurses, 
clinical social workers, marriage and family therapists, 
clinical mental health counselors, and psychosocial 
rehabilitation specialists. The need for mental health 
services is expected to continue to grow. 

Issues 

The evolving health care system is possibly the biggest 
issue now facing psychologists as well as the other mental 
health occupations. The much talked about managed care 
approach, which would work to constrain costs by 
substituting less costly providers, would likely result in a 
change in the utilization of various mental health 
providers. The more restrictive managed care system 



could also result in more intensive, short-term services that 
ultimately would require training programs to adjust 
accordingly. 

Currently, there is little data on how cost-effective it 
would be to extend reimbursement to those specialists not 
currently eligible. Additional research is therefore needed 
to identify discipline specific competencies and to 
anticipate and overcome competition for limited resources. 

Another issue is the need for psychologists to be more 
cognizant of consumer needs. Examples include the need 
to integrate the physical and mental health needs of 
special populations, such as the aged. Educators should 
also be ready to affect educational changes. For instance, 
recent research on biologically-based mental illnesses 
could result in the need to de-emphasize psychotherapy in 
favor of multiple modalities. This in turn raises concerns 
about prescriptive authority and would signal a need for 
greater collaboration with physicians. 

The need to foster collaboration among disciplines, and 
between academics and service providers is also crucial. 
Collaboration between educational programs is needed to 
train multiple professional mental health students such as 
psychiatrists, psychologists, psychiatric social workers, 
psychiatric nurses, psychosocial rehabilitation and mental 
health counselors, and marriage and family therapists. 
Schools that develop such cooperative agreements are 
likely to determine how public mental health care will be 
delivered in the next century. 

Our thanks to the Substance Abuse and Mental Health 
Services Administration and the National Institute of 
Mental Health for permitting the Bureau to draw heavily 
from their publication, Mental Health, United States, 1992. 
We strongly recommend this publication for a more 
complete understanding of the complex mental health 
industry and of mental health practitioners. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 103 



104 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Clinical Social Workers 

Stephen Tise, Office of Health Professions Analysis and Research, BHPr. 



Many States license social workers at three levels 
corresponding to levels of education: bachelors, masters, 
and doctorate. The provision of mental health services 
generally requires the services of a clinical social worker 
who must have completed a master's degree in social 
work (MSW). Not all MSW's, however, are clinical social 
workers. Clinical social workers generally provide face-to- 
face diagnostic, preventive care, and treatment to either 
individuals or groups. As an adjunct, clinical social 
workers may also provide case management services, such 
as coordinating care after a lengthy hospital stay, or 
directing clients to individuals or agencies capable of 
helping them with housing, employment, financial 
management and job training. 

Because specific educational attainment data for clinical 
social workers is not available, MSW data serves as a 
proxy representing an upward bound on the number of 
clinical social workers that might graduate each year. 
Enrollments and graduates in MSW programs dipped 
during the mid-1980's, and then rose 22 percent above 
1979-80 levels to 27,420 students and 10,063 graduates in 
1989-90. 

As with psychology, women represent an increasing 
proportion of students in MSW programs: 82 percent in 
1989-90, up from about 76 percent in 1979-80. Minorities 
remain underrepresented. 

Reliable supply estimates for clinical social workers do 
not exist. Also lacking is an accurate estimate of demand 
because other mental health professionals can and often do 
substitute for clinical social workers. As a result, demand 
for clinical social workers in the mental health arena is 
very flexible. Some of the mental health occupations 



capable of substituting for clinical social workers include 
psychiatrists, clinical psychologists, psychiatric nurses, 
marriage and family therapists, clinical mental health 
counselors, and psychosocial rehabilitation specialists. 
Clearly, however, demand for clinical social workers could 
increase should the demand for services provided solely 
by this occupation also increase. As more underserved, 
poor, or those with functional problems enter the system, 
there will be a greater need for social workers to provide 
such services as case management to get them back on 
their feet. 

Issues 

Clinical social workers are facing many of the same 
issues as clinical psychologists. The most important single 
issue now facing clinical social workers is the evolving 
health care system. The currently favored managed care 
approach, which would work to constrain costs by 
identifying and then substituting less costly providers, 
would likely alter the use of various mental health 
providers. How this would affect demand for clinical 
social workers is unknown. The more restrictive managed 
care system could also result in more intensive, short term 
services that would ultimately require training programs 
to adjust accordingly. 

Another issue is the need for these occupations to be 
more cognizant of consumer needs, such as the need to 
integrate the physical and mental health requirements of 
special populations, such as the aging. Educators also 
should be better prepared to affect educational changes. 
For instance, recent research on biologically-based mental 
illnesses could result in the need to de-emphasize 
psychotherapy in favor of multiple modalities. In turn, 
any trend toward increased use of drug therapy would 
also bring up issues of prescriptive authority and the need 
for greater collaborative arrangements with physicians. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 205 



The need to foster collaboration among disciplines, and 
between academics and service providers is therefore 
crucial. Collaboration between educational programs is 
needed to train the entire gamut of such mental health 
providers as psychiatrists, psychologists, psychiatric social 
workers, psychiatric nurses, psychosocial rehabilitation 
and mental health counselors, and marriage and family 
therapists. Schools that develop such cooperative 
agreements are likely to be in the vanguard of those 
determining how mental health care will be delivered in 
the next century. 

Preparation of this section on clinical social workers 
relied heavily on the Substance Abuse and Mental Health 
Services Administration's and the National Institute of 
Mental Health's report, Mental Health, United States, 1992. 
The Bureau strongly recommends this report to those 
wishing a more complete understanding of the complex 
health/mental health sector and of health/mental health 
providers. 



106 • Health Personnel in the United States • Ninth Report to Congress • 1993 



Veterinarians 



Stephen Tise, Office of Health Professions Analysis and Research, BHPr. 



Veterinarians contribute significantly to human well- 
being by performing food inspection, disease control, pet 
care, and medical research. 

The Bureau of Labor Statistics (BLS) estimates that 
veterinarians held some 47,000 jobs in 1990 and projects 
employment will grow to 62,000 by 2005, a 31 percent 
increase. 1 Factors contributing to the projected growth 
include the movement of baby boomers into the 34 to 59 
age bracket where pet ownership is highest; the 
willingness of pet owners to pay for the high-tech, high- 
priced care now becoming available; ongoing efforts to 
improve the breeding and raising of livestock; and the 
growing role of veterinarians in disease control and public 
health activities. 2 In addition, veterinarians might also 
begin to play a larger role in the protection of endangered 
species. 



Figure 24 

Veterinarians: 
First-Year Enrollments and Graduates 



2750 



2500 



2250 



2000 



1750 



1500 




J I I L 



1 979 1 980 1 981 1 982 1 983 1 984 1 985 1 986 1 987 1 988 1 989 1 990 1 991 1 992 
Year 

First-Year Enrollments ^^bbw Graduates 

Source: Association of American Veterinary Medical Colleges 



Unlike physicians, most veterinarians are generalists, so 
there is a limited availability of specialty services. 3 About 
75 percent of private practices are dedicated to companion 
animals, while the rest work with livestock and other 
species. 3 Currently, 27 programs educate veterinarians. 
The following graph provides trend data on first-year 
enrollments and graduates. 

Issues 

Because humans place increasing value on animals, 
veterinarians will play an important role in helping to 
address the ethical questions that result from the use of 
animals in medical experiments and product-testing. 

Veterinary medicine also needs to be more involved in 
addressing problems of disease, high concentrations of 
chemicals and hormones, all problems associated with 
large, high-technology farming. 1 

References 

1. Silvestri, G., Lukasiewicz, J. "Occupational Employment 

Projections". Monthly Labor Review. November 1991. 

2. Office of Employment Projections, Occupational Outlook 

Handbook, 1992-93, (Washington, D.C.: U.S. 
Department of Labor, May 1992). 

3. Pew Health Professions Commission, Health Professions 

Education of the Future: Schools in Service to the Nation. 
Feb. 1993. 



1993 • Health Personnel in the United States • Ninth Report to Congress • 107 



Figures 

1. Declining Interest in Primary Care Careers 18 

2. Registered Nurse Population With Advanced 
Practice Preparation, 1992 21 

3. PA Prescribing Authority by State 28 

4. Distribution of PAs in Rural Practice by State 

Laws on Prescribing Authority 29 

5. Supply of Active Physicians (MD and DO) and 
Ratio to Population 53 

6. Applicants and First- Year Enrollments in 

Schools of Medicine and Osteopathy 53 

7. Total Enrollments in PA Training Programs, 
1984-93 60 

8. Practicing Physician Assistants in U.S. by 
Generalist/Specialty Distribution 61 

9. Dental School Enrollments and Graduates 63 

10. Full-Time Equivalent Nursing Personnel 
Employed by Community Hospitals, 1981-1991 67 

11. Full-Time Equivalent Nursing Personnel in 
Medicare-Certified Home Health Agencies 68 

12. Graduations From Basic Programs Preparing 

for RN Licensure 69 

13. Registered Nurse Population by Nursing 
Employment Status 69 

14. Age Distribution of Registered Nurse Population, 
March 1988 and 1992 70 

15. Projected Growth: 1990-2005 and 2005 
Employment Levels (in millions) 73 

16. Graduates of PT Programs, 1981-1991 77 

17. Enrollments and Graduates of OT Programs 79 

18. Enrollments in RT and RTT Programs 83 

19. Graduates of RT and RTT Programs 83 



20a. Graduates of Nuclear Medicine, Radiation 

Therapy and Sonography Programs 87 

20b. Graduates of Radiographer Programs 87 

21. Enrollments and Graduates of Clinical 

Lab Programs 91 

22. First- Year Enrollments and Graduates of 

Schools of Pharmacy 95 

23. Graduates of Optometry Programs 97 

24. Veterinarians: First- Year Enrollments 

and Graduates 107 

Tables 

1. Estimated Percent of Women Practitioners in 
Selected Health Professions 32 

2. Percent Change in the Numbers of First Professional 
Degrees Conferred to Women by Health Field of 
Study and Race /Ethnicity, 1981-1990 34 

3. Projected Population in Selected Demographic 
Groups by Race /Ethnicity and Percent Change 
1992, 2000, and 2020 35 

4. Estimated Numbers of HIV-infected Persons in the 
United States and Numbers Estimated to be 
Receiving Regular Primary Care Services, According 
to the Severity of Their Illnesses, 1991 48 

5. Estimated FTE Health Personnel Providing 
Primary Care to Patients in High and Low 
Volume HIV Care Settings, 1991 49 

6. FTE Staff to Patient Ratios in Nursing Homes 
Providing HIV/AIDS Care According to 
Category of Health Personnel, 1992 50 



108 • Health Personnel in the United States • Ninth Report to Congress • 1993 



1993 • Health Personnel in the United States • Ninth Report to Congress • 109 



220 • Health Personnel in the United States • Ninth Report to Congress • 1993 



U. S. Department of Health & Human Services 
Public Health Service 



^~\C-», Health Resources and Services Administration 
'^-la^? Bureau of Health Professions